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Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
The Spirit of Collegiality.............................1
From the Executive Director:
Internet Prescribing....................................1
On the Necessity of Medical Chaperones .......4
NCMB Seeks Medical Coordinator................4
Two New Position Statements Adopted by
NCMB: Relate to Internet Prescribing
and Closing of Practice.............................5
What Are the Position Statements of the
NCMB and to Whom Do They Apply?....5
NCMB Adopts Position Statement on End-of-
Life Responsibilities and Palliative
Care, Joins Pharmacy and Nursing
Boards in Combined Statement................6
NCMB Amends Two Position Statements......7
President’s
Message
From the
Executive
Director
Wayne W. VonSeggen, PA-C Andrew W. Watry
No. 4 1999
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
The Spirit of Collegiality
After five years on the North Carolina
Medical Board, it is a special honor for me to
have been nominated and elected by my fel-low
Board members to be the president for
the coming year. At one time or another in
the past, most of us have wondered what we
would be doing when the year 2000 rolled
around. Years ago, when I became interest-ed
in a possible medical career, I would never
have guessed that I would come to this
unique position of responsibility.
I remember early in my life reading the
book The Brothers Mayo, which recounted
the lives of the great pioneer physicians and
surgeons, Will and Charles Mayo. Their
great skill as early American diagnosticians
and bold surgeons sparked the formation of
what is now known as the Mayo Clinic in
Rochester, Minnesota. I dreamed of enter-ing
the medical profession and somehow
contributing to the bettering of people’s
lives through application of medical knowl-edge
and entrepreneurial creativity. The
comradeship and team spirit that Will and
Charles Mayo seemed to have in augmenting
each other, and in building a system of
health care that would outlive them, pre-sented
a challenge for me and for lots of
other young people interested in getting into
the medical field.
I made the choice of entering into physi-cian
assistant training. I selected the
Bowman Gray Physician Assistant Program
here in Winston-Salem and graduated in
1977. Being a physician assistant has
brought me a sense of being able to help my
patients directly and to participate in the joy
of problem solving within medicine that I
had so deeply desired. I knew I had found
my niche in life. My twenty-two years prac-ticing
as a physician assistant here in North
Carolina have been very rewarding since
they have allowed me to work side-by-side
with physicians, other physician assistants,
nurse practitioners, and nurses. The team
concept of physician assistants working as
dependent practitioners with a physician, or
a group of physicians, requires constant
communication between team members in
Internet Prescribing
I am summarizing below key excerpts
from a solicitation we recently received
online through America On Line (AOL).
The solicitation was entitled, Special
Bulletin: Solicitation of Docs for Internet
Prescribing.
Hello. Pardon me for the random
intrusion. . . . I saw you online under
“physician” on AOL. We have set up a net-work
of doctors who are interested in help-ing
patients online with non-critical care pre-scriptions.
This is cutting-edge medical
practice. You are given the opportunity to
help many people at one time and your com-pensation
is very nice. . . . We have a strong
organization and refuse to dispense meds
unethically, or illegally as many organizations
have been doing on the Internet. . . .
Candidates must be able to prescribe med-ications
such as Propecia, Viagra, Merida
and Claritin. . . . Our goal is to increase the
amount of care offered to people who cannot
get to see a doctor and/or who are too
embarrassed to go talk about their erectile
dysfunction in person. NOTE: Doctors will
make up to $12,500 per month for script
approval. Here is how our system works:
patients seeking help will log into our sys-tem,
fill-out a detailed questionnaire which
will be forwarded to you, and then you will
have the option to approve or disapprove
their request. E-prescriptions will be for-warded
to our pharmacy and the medica-tions
will be sent. . . . There is an immediate
need for five doctors in each state. . . . They
will all come from various states, so those
wont [sic] all be for one doctor however the
script rate is $20 per approval. A single doc-tor
will likely approve 10-100 per day on the
average. These would take only a few min-utes
each to look over. You can do the math.
forum
continued on page 3
continued on page 2
Special Notice of Hearing and Comment
Period on Proposed Amendment
to Rules: NCMB Continuing Education
Requirements ...........................................8
NCMB Seeks Medical Coordinator................8
Review: State Medical Boards and the
Politics of Public Protection ..........................9
Identification Badges Required as of
October 1, 1999.......................................9
NCMB Position Statements .........................10
NCMB Seeks Medical Coordinator..............17
Board Actions: 8/1999-10/1999 ..................18
Board Calendar............................................23
Change of Address Form .............................24
Important Notice.........................................24
FOCUS ON
NCMB POSITION STATEMENTS
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. IV, No. 4, 1999
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Wayne W. VonSeggen, PA-C
President
Winston-Salem
Term expires
October 31, 2000
Elizabeth P. Kanof, MD
Vice President
Raleigh
Term expires
October 31, 1999
Walter J. Pories, MD
Secretary-Treasurer
Greenville
Term expires
October 31, 2000
Kenneth H. Chambers, MD
Charlotte
Term expires
October 31, 2001
John T. Dees, MD
Cary
Term expires
October 31, 2000
John W. Foust, MD
Charlotte
Term expires
October 31, 2000
Hector H. Henry, II, MD
Concord
Term expires
October 31, 1999
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2001
Paul Saperstein
Greensboro
Term expires
October 31, 2001
Charles E. Trado, MD
Hickory
Term expires
October 31, 1999
Martha K. Walston
Wilson
Term expires
October 31, 1999
Andrew W. Watry
Executive Director
Helen Diane Meelheim
Assistant Executive Director
Bryant D. Paris, Jr
Executive Director
Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Editorial Assistant
Jennifer L. Deyton
Mailing Address
Forum
NC Medical Board
PO Box 20007
Raleigh, NC 27619
Street Address
1201 Front Street
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.docboard.org/nc
E-Mail:
ncmedbrd@interpath.com
The Spirit of Collegiality
continued from page 1
order to deliver high quality health care ser-vices
to our patients.
My participation on the North Carolina
Medical Board since 1994 has provided me
a regulator’s view to see how the various
medical professions here in this state have
been able to build great opportunities for a
variety of medical professionals. Several
groups of health care providers have pro-gressed
significantly in this supportive envi-ronment.
Nurse practitioners have gained
the opportunity to develop true collabora-tive
practice agreements in which their
nursing and clinical management skills can
be used more effectively. The Board, in
cooperation with the Office of Emergency
Medical Services, has developed an excel-lent
system for our emergency medical per-sonnel
to be used to their maximal skill lev-els,
yet with a high degree of physician
involvement and support. Physicians in
training have been encouraged to be sensi-tive
to the dangers of overextending them-selves
during residencies, and to be alert for
early signs of substance abuse and impair-ment
even during their residency years.
Improvements in the legislative and reg-ulatory
climate here in North Carolina have
permitted physician assistants to be fully uti-lized
professionally. For those physicians or
groups of physicians who have incorporated
the use of physician assistants in their prac-tices,
mutual interdependence and respect
have provided each with positive reinforce-ment
that the MD-PA team is a great idea.
As increased recognition of the physician
assistant profession has matured, so have the
relationships of the North Carolina Medical
Board with the North Carolina Academy of
Physician Assistants and the North Carolina
Medical Society.
In my opinion, North Carolina possesses
an environment that has fostered the best
statutes and regulations for physician assis-tant
practice in the entire nation. Physician
assistants have been invited to be full mem-bers
of the North Carolina Medical Society
and can participate in the Society’s House of
Delegates through its “PA Section.” The
North Carolina Physicians Health Program
assists recovering physicians and physician
assistants. Continuing medical education
providers encourage CME training for
physicians and other members of the health
care team. Private, state, and federal
employers routinely include physician assis-tants
and nurse practitioners on their cost-effective
health care delivery teams in a vari-ety
of primary care and specialty practices.
Managed care systems now may include
physician assistants and nurse practitioners
in their provider bulletins. The General
Assembly has contributed to the permanent
representation of mid-level practitioners by
the addition of a full board member position
for “at least one physician assistant or nurse
practitioner” on the North Carolina Medical
Board.
For the Board to choose a non-physician
to hold a position as one of its officers speaks
volumes for the courage, the maturity, and
the comfort level of the current Board. The
friendship and sincere collegiality of the cur-rent
members of the Board have provided an
opportunity for me (and perhaps future
mid-level health care practitioners) to share
in the responsible governance of the medical
profession in this state. The growth of
respect and collegiality in North Carolina
between physicians and the PA/NP profes-sions
has blossomed into a beautiful situa-tion
that I hope could serve as a model in
many other states. Patients (the public) are
the clear winners when the medical team
functions cooperatively and efficiently with
professional respect for what each member
of that team can contribute.
I have been honored to follow Mr Paul
Saperstein, a public member of the Board, as
president. Mr Saperstein served and guided
the North Carolina Medical Board with
great distinction and excellent management
skills. He has been sensitive to the charge to
protect the public while properly regulating
the medical profession. The other members
of the Board constantly interact and provide
support in areas where a public member or a
physician assistant member may lack exper-tise.
The beauty of the functioning of the
Board is that the decisions and actions reflect
the wisdom, creativity, and sensitivity of all
its members, no matter who the officers may
be.
I look forward to this new year of service
on the Board, and I hope to be available to
all licensees of the Board. The North
Carolina Medical Board and our competent
staff hope to improve communications with
you even more, and to assure our citizens
that our concerted efforts will provide North
Carolinians with the best medical practice
environment in America for physicians,
physician assistants, nurse practitioners, and
EMS personnel. Our availability to you
through the Forum and electronic methods,
including Web page, e-mail, and state of
the art telephone system, shows our
determination to provide North Carolinians
with the best possible service. You may
contact me through the Board or via E-mail
at wvonseggen@aol.com. u
No. 4 1999 3
Internet Prescribing
continued from page 1
1-800-253-9653
North Carolina
Medical Board
It is projected that the number of people
using the Internet for health and medical
information will reach 30 million this year,
rising from 7.8 million in 1996. Part of the
attraction of the
Internet is the
fact that it is a
laissez-faire mar-ketplace.
That is
also part of the
problem when it
comes to pre-scription
med-ications.
The
Internet can be a
valuable source
of information.
However, it can
also be a place where prescription drugs can
be purchased without benefit of the signifi-cant
patient protection mechanisms devel-oped
in this country over the past century.
A recent article in the New England
Journal of Medicine highlights the problem
as it relates to sildenafil citrate (Viagra®).
The authors focused their survey on Web
sites offering direct sale of this drug to con-sumers.
Their findings: they identified 86
sites that offered to deliver sildenafil citrate
directly to consumers without a visit to a
physician. Only 27 sites specified that a
physician would review each questionnaire.
Their findings document that sildenafil cit-rate
is readily obtainable over the Internet
without the need for a visit to a physician
or review by a pharmacist. They conclude:
“the ability to buy drugs over the Internet
means that important safeguards intrinsic
to conventional prescribing and related to
the physician-patient relationship are
bypassed.” They recommend: “in the light
of our findings we believe that state licens-ing
boards for physicians and pharmacists
should move quickly to establish and
enforce guidelines for the involvement of
U.S. clinicians in prescribing drugs over the
Internet.”
Some of the vendors for Internet pre-scribing
are making a credible effort to
build patient protection mechanisms, such
as providing responsible physician over-sight
in the process. However, it is clear
that many sites are not providing such pro-tection.
It is equally clear that in spite of
whatever mechanisms are provided for
online physician consultation, it is far too
easy for a “patient” to dupe the prescribing
physician without a personal encounter.
In response to a question from a member
of the Medical Board, we ordered some
Viagra® online in this office. We filled out a
short questionnaire and took delivery of a
substance represented as Viagra® in less than
24 hours. It was delivered to our offices
along with our other mail. It was delivered
via Federal Express. Some may argue that
current regulation is excessive. However, we
have the following questions and we expect
that many consumers would have similar
questions.
l Was the substance Viagra®? It could
easily have been a sugar pill.
l Where had this substance been stored
and how had it been transported? If we
picked it up at a pharmacy, the pharma-cist
would be responsible for giving us
patient information, including informa-tion
about medications that should not
be taken with this drug. The pharma-cist
would be responsible for making
sure we do not get an outdated drug,
that it is in fact Viagra®, that it is in an
appropriately labeled package, and that
it is the result of a legitimate prescrip-tion.
None of those safeguards were in
place with the sample we received. In
fact, we can find no physician (MD or
DO) in the entire country who has the
name of the alleged physician whose
name appears on the bottle. We did
verify that he was not in North Carolina
and we forwarded the matter to appro-priate
enforcement authorities.
l How do we know whether this drug
was stored in somebody’s hot attic or
car trunk or whether it was legitimately
stored and handled by an appropriately
licensed, trained pharmacist?
l Suppose a complication arises? Is that
anonymous person authorizing the pre-scription
at the other end of the Web
site available to help with local medical
care in the event of such a complica-tion?
l What would prevent a 16-year-old from
gaming the questionnaire to get and
perhaps sell the drug?
These and other issues are a matter of con-cern
to many, if not most of the medical
boards in this country. As Armstrong,
Schwartz, et al, noted in their NEJM article,
it is appropriate for state medical and phar-macy
boards to move quickly to establish
and enforce guidelines for the involvement
of U.S. clinicians in prescribing drugs over
the Internet.
Your North Carolina Medical Board has
issued a position statement entitled Contact
With Patients Before Prescribing that deals
with this issue directly. This position state-ment
may be found in this number of the
Forum and on our Web site. It gives physi-cians
holding North Carolina licenses guid-ance
that leads
to the following
statement: “It
is the position
of the Board
that prescribing
drugs to indi-viduals
the
physician has
never met based
solely on
answers to a set
of questions, as
is common in
Internet or toll-free telephone prescribing, is
inappropriate and unprofessional.”
The Federation of State Medical Boards is
formulating recommendations to all of the
licensing boards in the United States on this
issue and these recommendations should be
available shortly. The U.S. Congress has
asked the General Accounting Office to con-duct
a study of online pharmacies and online
physician prescribing practices; and
President Clinton has proposed giving the
Food and Drug Administration new powers
to review and certify drug-dispensing Web
sites. We will advise you of any significant
developments at the federal level.
In conclusion, the Internet is nothing
more than a much improved mechanism for
communicating information. No one on
our Medical Board or in the field of medical
regulation, to my knowledge, is interested in
shooting the messenger. The principal con-cern
is that the Internet also provides a
mechanism for circumventing time-tested
safeguards when it comes to prescribing
dangerous drugs.
Imagine the pub-lic
harm if phen-fen
had been as
readily available
on the Internet
as Viagra® is
now.
The medical
boards in this
country are very
diverse, but they
all have one
thing clearly in common: a legislative man-date
to protect the public. The North
Carolina Medical Board takes this regulatory
responsibility seriously; it does not want to
be in the position of waiting until people are
harmed before it reacts. That was the dri-ving
force for the development of its recent
position statement on the subject. We will
try to keep you updated on developments in
this important area. u
“It is appropriate for
state medical and
pharmacy boards to
move quickly to
establish and enforce
guidelines for the
involvement of U.S.
clinicians in pre-scribing
drugs over
the Internet.”
“It is projected that
the number of peo-ple
using the
Internet for health
and medical infor-mation
will reach
30 million this
year, rising from
7.8 million in
1996.”
“The principal con-cern
is that the
Internet also pro-vides
a mechanism
for circumventing
time-tested safe-guards
when it
comes to prescribing
dangerous drugs.”
4 NCMB Forum
The need for chaperones during gyneco-logic
examinations has been of particular
interest to the American Society of Forensic
Obstetricians and Gynecologists (ASFOG)
for a number of years, evidenced by our
Newsletter’s addressing the issue on multiple
occasions with original articles, letters to the
editor, and reprints of other relevant research
and opinions.1-9 The American College of
Obstetricians and Gynecologists (ACOG)
has also addressed the issue in multiple pub-lications.
10-14
All the above agree with a recent article in
the North Carolina Medical Board’s Forum
[Vol. IV, No. 3 (1999), p.11, Don’t
Underestimate the Importance of
Chaperones] recommending the use of
chaperones when physicians examine partial-ly
or completely disrobed patients of the
opposite sex. ASFOG goes even further by
recommending use of an employee chaper-one,
preferably of the same sex and prefer-ence
(if known) as the patient, for all breast,
genital, or rectal examinations regardless of
the sex or preference of patient or physician.
Another recent article in a major peer-reviewed
medical journal may, however, be
construed by some as downplaying the
importance of chaperones.15 It reports
results of a survey of 67 U.S. state medical
and osteopathic licensing boards on their
policies, opinions, positions, or laws regard-ing
the use of chaperones in gynecologic
examinations. The authors observe there
was “no consensus among state medical
boards on the use of chaperones,” with
almost ten percent (6) failing to respond to
the authors’ queries despite three formal
requests. Over half those replying had no
position on the use of chaperones, possibly
indicating chaperones are unnecessary. The
authors’ closing remark, “it is important to
give physicians direction on this issue,” is
certainly an understatement.
For years, ACOG’s publications have
advocated chaperone use with comments
ranging from “can confer benefits”10 and
“advisable”12 to “should be present,”13
“strongly recommended,”11 and “is a must.”14
Our ASFOG Newsletter has supported simi-lar
recommendations and opinions, such as
“require(d),”1 “never. . .without,”2 “need-ed,”
4 “nurse should be present whenever a
pelvic examination is performed,” 5 and
“require(d).”8
Although no regulatory body or national
medical organization requires or probably
ever will require their routine use during
COMMENTARY
On the Necessity of Medical Chaperones
William D. Daniel, MD, Executive Director
American Society of Forensic Obstetricians and Gynecologists
breast, genital, or rectal examinations, chap-erones
are the only available defense for
patients against the relatively rare physician’s
sexual improprieties and for physicians
against the equally rare patient’s unsubstan-tiated
charges of sexual impropriety or even
assault. Considering the stakes, we should
just do it!
NOTES
1. L. Iffy, “Must Female Physicians Have
Chaperones?” OB-GYN Malpractice Prevention 1,
No.7 (1994): 7. [Naples, FL: Global Success
Corporation.] Reprinted in The Medicolegal
OB/GYN Newsletter 4, No. 4 (1996).
2. D. Daniel, “Ms Lovelace, Sen. Packwood, and
Dr. Hill,” The Medicolegal OB/GYN Newsletter 4,
No. 1 (1996): 1-5.
3. “Are Chaperones Needed in Anesthesia?”
Anesthesia Malpractice Prevention Special Report
(Naples, FL: Global Success Corporation, May
1996). Reprinted in The Medicolegal OB/GYN
Newsletter 4, No. 4 (1996).
4. “Chaperones Not Used Regularly; Risk Said
High,” OB-GYN Malpractice Prevention 3, No. 9
(1996): 65-67. [Naples, FL: Global Success
Corporation.] Reprinted in The Medicolegal
OB/GYN Newsletter 4, No. 4 (1996).
5. R.E. Anderson, “Report of Sexual Misconduct
Claims Review Panel” (San Diego: The Doctors’
Company, November 1996). Reprinted in The
Medicolegal OB/GYN Newsletter 6, No. 4 (1998):
36-40.
6. R.E. Anderson, “Letter to the Editor,” The
Medicolegal OB/GYN Newsletter 7, No. 1 (1999): 8.
7. E.M. Levine, “Letter to the Editor,” The
Medicolegal OB/GYN Newsletter 7, No. 1 (1999): 6-7.
8. J. Feeley, “Drafting an Airtight Sexual
Harassment Policy,” Physician’s Practice Digest
(March/April 1999): 26-27.
9. W.H. Hindle, “Letter to the Editor,” The
Medicolegal OB/GYN Newsletter 7, No. 3 (1999): 7-9.
10. American College of Obstetricians and
Gynecologists, Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations:
ACOG Committee Opinion No. 144 (Washington,
1994): 2.
11. American College of Obstetricians and
Gynecologists, Guidelines for Women’s Health Care
(Washington, 1995): 22, 86, 87, 142.
12. American College of Obstetricians and
Gynecologists, Sexual Dysfunction: ACOG
Educational Bulletin No. 211 (Washington, 1995): 6.
13. American College of Obstetricians and
Gynecologists, Sexual Assault: ACOG Bulletin No.
242 (Washington, 1997): 3.
14. “Chaperones May Keep Ob-Gyns Out of the
Courtroom,” ACOG Today 43, No. 7 (1999): 12.
15. S.J. Stagno et al, “Medical and Osteopathic
Boards’ Positions on Chaperones During
Gynecologic Examinations,” Obstet Gynecol 94
(1999): 352-354. u
NORTH
CAROLINA
MEDICAL BOARD
SEEKS MEDICAL
COORDINATOR
The North Carolina
Medical Board is recruiting
to fill a vacancy in the staff
position of Medical
Coordinator. The physi-cian
filling this position
will review, evaluate, and
make recommendations to
the Board about reports
concerning the conduct
and/or performance of
physicians licensed to prac-tice
medicine in North
Carolina.
Any physician interested
in being considered for the
full time position of
Medical Coordinator must
hold a full and unrestricted
North Carolina medical
license and should submit a
curriculum vitae to:
Mr Andrew Watry,
Executive Director
North Carolina
Medical Board
PO Box 20007
Raleigh, NC 27619
or
info@ncmedboard.org.
All inquiries regarding
this position should be
made in writing and be
directed to Mr Watry at
either of the addresses
above. Application dead-line
is March 15, 2000.
No. 4 1999 5
What Are the Position Statements of the NCMB
and to Whom Do They Apply?
The North Carolina Medical Board’s Position Statements are interpretive statements that
attempt to define or explain the meaning of laws or rules that govern the practice of physicians,*
physician assistants, and nurse practitioners in North Carolina, usually those relating to discipline.
They also set forth criteria or guidelines used by the Board’s staff in investigations and in the pros-ecution
or settlement of cases.
When considering the Board’s Position Statements, the following four points should be kept in
mind.
1. In its Position Statements, the Board attempts to articulate some of the standards it believes
applicable to the medical profession and to the other health care professions it regulates.
However, a Position Statement should not be seen as the promulgation of a new standard as of
the date of issuance or amendment. Some Position Statements are reminders of traditional, even
millennia old, professional standards, or show how the Board might apply such standards today.
2. The Position Statements are not intended to be comprehensive or to set out exhaustively
every standard that might apply in every circumstance. Therefore, the absence of a Position
Statement or a Position Statement’s silence on certain matters should not be construed as the
lack of an enforceable standard.
3. The existence of a Position Statement should not necessarily be taken as an indication of the
Board’s enforcement priorities.
4. A lack of disciplinary actions to enforce a particular standard mentioned in a Position
Statement should not be taken as an abandonment of the principles set forth therein.
The Board will continue to decide each case before it on all the facts and circumstances presented
in the hearing, whether or not the issues have been the subject of a Position Statement. The Board
intends that the Position Statements will reflect its philosophy on certain subjects and give licensees
some guidance for avoiding Board scrutiny. The principles of professionalism and performance
expressed in the Position Statements apply to all persons licensed and/or approved by the Board to
render medical care at any level.
*The words “physician” and “doctor” as used in the Position Statements refer to persons who are
MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina.
[Adopted by the NCMB in 11/1999.] u
Two New Position Statements Adopted by NCMB:
Relate to Internet Prescribing and Closing of Practice
The North Carolina Medical Board recently
adopted two new position statements, one
related to the importance of a physician’s hav-ing
personal contact with a patient prior to pre-scribing
and the other dealing with closing or
leaving a medical practice. The first, adopted
in November 1999, is of particular interest in
relation to Internet prescribing. The second,
adopted in January 2000, is focused on the
problems faced when practices undergo
changes that could affect the continuity of
patient care.
CONTACT WITH PATIENTS
BEFORE PRESCRIBING
It is the position of the North Carolina
Medical Board that prescribing drugs to an
individual the prescriber has not personally
examined is usually inappropriate. Before pre-scribing
a drug, a physician should make an
informed medical judgment based on the cir-cumstances
of the situation and on his or her
training and experience. Ordinarily, this will
require that the physician personally perform
an appropriate history and physical examina-tion,
make a diagnosis, and formulate a thera-peutic
plan, a part of which might be a pre-scription.
This process must be documented
appropriately.
Prescribing for a patient whom the physician
has not personally examined may be suitable
under certain circumstances. These may
include admission orders for a newly hospital-ized
patient, prescribing for a patient of anoth-er
physician for whom the prescriber is taking
call, or continuing medication on a short-term
basis for a new patient prior to the patient’s
first appointment. Established patients may
not require a new history and physical exami-nation
for each new prescription, depending on
good medical practice.
It is the position of the Board that prescrib-ing
drugs to individuals the physician has never
met based solely on answers to a set of ques-tions,
as is common in Internet or toll-free tele-phone
prescribing, is inappropriate and unpro-fessional.
(Adopted 11/1999)
DEPARTURES FROM OR CLOS-INGS
OF MEDICAL PRACTICES
Departures from (when one or more physi-cians
leave and others remain) or closings of
medical practices are trying times. They can be
busy, emotional, and stressful for all concerned:
practitioners, staff, patients, and other parties
that may be involved. If mishandled, they can
significantly disrupt continuity of care. It is the
position of the North Carlina Medical Board
that during such times practitioners and other
parties that may be involved in such processes
must consider how their actions affect patients.
In particular, practitioners and other parties
that may be involved have the following oblig-ations.
Permit Patient Choice
It is the patient’s decision from whom to
receive care. Therefore, it is the responsibility
of all practitioners and other parties that may
be involved to ensure that:
l patients are notified of changes in the
practice, which is often done by newspa-per
advertisement and by letters to
patients currently under care;
l patients are told how to access their med-ical
records;
l patients are told how to reach any practi-tioner(
s) remaining in practice; and
l patients clearly understand that the choice
of a health care provider is the patients’.
Provide Continuity of Care
Practitioners continue to have obligations
toward patients during and after the depar-ture
from or closing of a medical practice.
Except in case of the death or other incapac-ity
of the practitioner, practitioners may not
abandon a patient or abruptly withdraw
from the care of a patient. Therefore,
patients should be given reasonable advance
notice to allow their securing other care.
Good continuity of care includes preserving,
keeping confidential, and providing appro-priate
access to medical records.* Also,
good continuity of care may often include
making appropriate referrals. The practi-tioner(
s) and other parties that may be
involved should ensure the requirements for
continuity of care are effectively addressed.
No practitioner, group of practitioners, or
other parties that may be involved should inter-fere
with the fulfillment of these obligations,
nor should practitioners put themselves in a
position where they cannot be assured these
obligations can be met.
*The Board’s position statement on the Retention
of Medical Records applies, even when practices
close permanently due to the retirement or death
of the practitioner.
(Adopted 1/2000) u
6 NCMB Forum
In October 1999, the North Carolina
Medical Board adopted the Position
Statement on End-of-Life Responsibilities
and Palliative Care that appears below. In
the same month, it joined with the North
Carolina Board of Pharmacy and the North
Carolina Board of Nursing in issuing a com-bined
statement on the same subject.
The NCMB adopted a statement on the
management of chronic non-malignant pain
in September 1996, following its sponsor-ship
of a special seminar on effective pain
control earlier that year. Along with the
Pharmacy and Nursing Boards, it also spon-sored
a special progam on end-of-life respon-sibilites
in October 1998. Adoption of the
two statements below reflects the NCMB’s
continuing commitment to actively address-ing
these issues.
END-OF-LIFE RESPONSIBILI-TIES
AND PALLIATIVE CARE
Assuring Patients
Death is part of life. When appropriate
processes have determined that the use of
life-sustaining or invasive interventions will
only prolong the dying process, it is incum-bent
on physicians to accept death “not as a
failure, but the natural culmination of our
lives.”*
It is the position of the North Carolina
Medical Board that patients and their fami-lies
should be assured of competent, com-prehensive
palliative care at the end of their
lives. Physicians should be knowledgeable
regarding effective and compassionate pain
relief, and patients and their families should
be assured such relief will be provided.
Palliative Care
There is no one definition of palliative
care, but the Board accepts that found in the
Oxford Textbook of Palliative Medicine: “The
study and management of patients with
active, progressive, far advanced disease for
whom the prognosis is limited and the focus
of care is the quality of life.” This is not
intended to exclude remissions and requires
that the management of patients be compre-hensive,
embracing the efforts of medical
clinicians and of those who provide psy-chosocial
services, spiritual support, and
hospice care.
A physician who provides palliative care,
encompassing the full range of comfort care,
NCMB Adopts Position Statement on End-of-Life Responsibilties
and Palliative Care, Joins Pharmacy and Nursing Boards
in Combined Statement
should assess his or her patient’s physical,
psychological, and spiritual conditions.
Because of the overwhelming concern of
patients about pain relief, special attention
should be given the effective assessment of
pain. It is particularly important that the
physician frankly but sensitively discuss with
the patient and the family their concerns and
choices at the end of life. As part of this dis-cussion,
the physician should make clear
that, in some cases, there are inherent risks
associated with effective pain relief in such
situations.
Opioid Use
The Board will assume opioid use in such
patients is appropriate if the responsible
physician is familiar with and abides by
acceptable medical guidelines regarding such
use, is knowledgeable about effective and
compassionate pain relief, and maintains an
appropriate medical record that details a
pain management plan. (See the Board’s
position statement on the Management of
Chronic Non-Malignant Pain for an outline
of what the Board expects of physicians in
the management of pain.) Because the
Board is aware of the inherent risks associat-ed
with effective pain relief in such situa-tions,
it will not interpret their occurrence as
subject to discipline by the Board.
Selected Guides
To assist physicians in meeting these responsi-bilities,
the Board recommends: Cancer Pain
Relief: With a Guide to Opioid Availability, 2nd ed
(1996), Cancer Pain Relief and Palliative Care
(1990), Cancer Pain Relief and Palliative Care in
Children (1999), and Symptom Relief in Terminal
Illness (1998), (World Health Organization,
Geneva); Management of Cancer Pain (1994),
(Agency for Health Care Policy and Research,
Rockville, MD); Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain, 4th
Edition (1999)(American Pain Society, Glenview,
IL); Hospice Care: A Physician’s Guide (1998)
(Hospice for the Carolinas, Raleigh); and the
Oxford Textbook of Palliative Medicine (1993)
(Oxford Medical, Oxford).
(Adopted 10/1999)
*Steven A. Schroeder, MD, President, Robert
Wood Johnson Foundation.
JOINT STATEMENT ON PAIN
MANAGEMENT IN END-OF-LIFE
CARE
(Adopted by the North Carolina Medical,
Nursing, and Pharmacy Boards)
Through dialogue with members of the
healthcare community and consumers, a
number of perceived regulatory barriers to
adequate pain management in end-of-life
care have been expressed to the Boards of
Medicine, Nursing, and Pharmacy. The fol-lowing
statement attempts to address these
misperceptions by outlining practice expec-tations
for physicians and other health care
professionals authorized to prescribe med-ications,
as well as nurses and pharmacists
involved in this aspect of end-of-life care.
The statement is based on:
l the legal scope of practice for each of
these licensed health professionals;
l professional collaboration and commu-nication
among health professionals
providing palliative care; and
l a standard of care that assures on-going
pain assessment, a therapeutic plan for
pain management interventions; and
evidence of adequate symptom man-agement
for the dying patient.
It is the position of all three Boards that
patients and their families should be assured
of competent, comprehensive palliative care
at the end of their lives. Physicians, nurses,
and pharmacists should be knowledgeable
regarding effective and compassionate pain
relief, and patients and their families should
be assured such relief will be provided.
Because of the overwhelming concern of
patients about pain relief, the physician
needs to give special attention to the effec-tive
assessment of pain. It is particularly
important that the physician frankly but sen-sitively
discuss with the patient and the fam-ily
their concerns and choices at the end of
life. As part of this discussion, the physician
should make clear that, in some end of life
care situations, there are inherent risks asso-ciated
with effective pain relief. The Medical
Board will assume opioid use in such patients is
appropriate if the responsible physician is famil-iar
with and abides by acceptable medical guide-lines
regarding such use, is knowledgeable about
effective and compassionate pain relief, and
maintains an appropriate medical record that
details a pain management plan. Because the
continued on page 7
No. 4 1999 7
NCMB Amends Two
Position Statements
At its meeting in January 2000, the North
Carolina Medical Board amended two of its
position statements to further clarify their
meaning. In modifying the final segment of
its Position Statement on the Physician-
Patient Relationship (see below), the Board
makes clear that the decision to terminate
Board is aware of the inherent risks associat-ed
with effective pain relief in such situa-tions,
it will not interpret their occurrence as
subject to discipline by the Board.
With regard to pharmacy practice, North
Carolina has no quantity restrictions on dis-pensing
controlled substances including
those in Schedule II. This is significant
when utilizing the federal rule that allows
the partial filling of Schedule II prescriptions
for up to 60 days. In these situations it
would minimize expenses and unnecessary
waste of drugs if the prescriber would note
on the prescription that the patient is termi-nally
ill and specify the largest anticipated
quantity that could be needed for the next
two months. The pharmacist could then
dispense smaller quantities of the prescrip-tion
to meet the patient’s needs up to the
total quantity authorized. Government-approved
labeling for dosage level and fre-quency
can be useful as guidance for patient
care. Health professionals may, on occasion,
determine that higher levels are justified in
specific cases. However, these occasions
would be exceptions to general practice and
would need to be properly documented to
establish informed consent of the patient
and family.
Federal and state rules also allow the fax
transmittal of an original prescription for
Schedule II drugs for hospice patients. If
the prescriber notes the hospice status of the
patient on the faxed document, it serves as
the original. Pharmacy rules also allow the
emergency refilling of prescriptions in
Schedules III, IV, and V. While this does not
apply to Schedule II drugs, it can be useful
in situations where the patient is using drugs
such as Vicodin for pain or Xanax for anxi-ety.
The nurse is often the health professional
most involved in on-going pain assessment,
implementing the prescribed pain manage-ment
plan, evaluating the patient’s response
to such interventions, and adjusting medica-tion
levels based on patient status. In order
to achieve adequate pain management, the
prescription must provide dosage ranges and
frequency parameters within which the
nurse may adjust (titrate) medication in
order to achieve adequate pain control.
Consistent with the licensee’s scope of prac-tice,
the RN or LPN is accountable for
implementing the pain management plan
utilizing his/her knowledge base and docu-mented
assessment of the patient’s needs.
The nurse has the authority to adjust medica-tion
levels within the dosage and frequency
ranges stipulated by the prescriber and accord-ing
to the agency’s established protocols.
However, the nurse does not have the
authority to change the medical pain man-agement
plan. When adequate pain man-agement
is not achieved under the currently
prescribed treatment plan, the nurse is
responsible for reporting such findings to
the prescriber and documenting this com-munication.
Only the physician or other
health professional with authority to pre-scribe
may change the medical pain manage-ment
plan.
Communication and collaboration
between members of the healthcare team,
and the patient and family are essential in
achieving adequate pain management in
end-of-life care. Within this interdisciplinary
framework for end of life care, effective pain
management should include:
l thorough documentation of all aspects
of the patient’s assessment and care;
l a working diagnosis and therapeutic
treatment plan including pharmacolog-ic
and non-pharmacologic interven-tions;
l regular and documented evaluation of
response to the interventions and, as
appropriate, revisions to the treatment
plan;
l evidence of communication among care
providers;
l education of the patient and family; and
l a clear understanding by the patient,
the family and healthcare team of the
treatment goals.
It is important to remind health profes-sionals
that licensing boards hold each
licensee accountable for providing safe,
effective care. Exercising this standard of
care requires the application of knowledge,
skills, as well as ethical principles focused on
optimum patient care while taking all appro-priate
measures to relieve suffering. The
healthcare team should give primary impor-tance
to the expressed desires of the patient
tempered by the judgement and legal
responsibilities of each licensed health pro-fessional
as to what is in the patient’s best
interest.
(Adopted 10/1999) u
NCMB Adopts Statements
continued from page 6
continued on page 8
the relationship with a patient must be made
by the physician personally, with written
notice given by the physician. In the
Position Statement on Laser Surgery (print-ed
in full below), an expansion of the first
paragraph makes clear that certain licensed
practitioners may perform laser surgery
under physician supervision.
TERMINATION OF THE PHYSI-CIAN-
PATIENT RELATIONSHIP
(Final Segment of the Position Statement on the
Physician-Patient Relationship)
The Board recognizes the physician’s right
to choose patients and to terminate the pro-fessional
relationship with them when he or
she believes it is best to do so. That being
understood, the Board maintains that termi-nation
of the physician-patient relationship
must be done in compliance with the physi-cian’s
obligation to support continuity of
care for the patient. The decision to termi-nate
the relationship must be made by the
physician personally. Further, termination
must be accomplished by appropriate writ-ten
notice given by the physician to the
patient, the relatives, or the legally responsi-ble
parties sufficiently far in advance (at least
30 days) to allow other medical care to be
secured. Should the physician be a member
of a group, the notice of termination must
state clearly whether the termination
involves only the individual physician or
includes other members of the group. In the
latter case, those members of the group join-ing
in the termination must be designated.
(Adopted 7/1995)
(Amended 7/1998, 1/2000)
LASER SURGERY
It is the position of the North Carolina
Medical Board that the revision, destruction,
incision, or other structural alteration of
human tissue using laser technology is
surgery.* Laser surgery should be per-formed
only by a physician or by a licensed
practitioner with appropriate medical train-ing
functioning under the supervision,
preferably on-site, of a physician or by those
categories of practitioners currently licensed
by this state to perform surgical services.
Licensees should use only devices
approved by the U.S. Food and Drug
Administration unless functioning under
protocols approved by institutional review
boards. As with all new procedures, it is the
licensee’s responsibility to obtain adequate
training and to make documentation of this
training available to the North Carolina
Medical Board on request.
Lasers are employed in certain hair-
8 NCMB Forum
NCMB Amends Statements
continued from page 7
removal procedures, as are various devices
that (1) manipulate and/or pulse light caus-ing
it to penetrate human tissue and (2) are
classified as “prescription” by the U.S. Food
and Drug Administration. Hair-removal
procedures using such technologies should
be performed only by a physician or by a
licensed practitioner with appropriate med-ical
training functioning under the supervi-sion,
preferably on-site, of a physician who
bears responsibility for those procedures.
*Definition of surgery as adopted by
the NCMB, November 1998:
Surgery, which involves the revision,
destruction, incision, or structural alteration
of human tissue performed using a variety of
methods and instruments, is a discipline that
includes the operative and non-operative
care of individuals in need of such interven-tion,
and demands pre-operative assessment,
judgment, technical skills, post-operative
management, and follow up.
(Adopted 7/1999)
(Amended 1/2000) u
SPECIAL NOTICE
OF HEARING AND
COMMENT
PERIOD ON PRO-POSED
AMEND-MENT
TO RULES:
NCMB Continuing
Medical Education
Requirements
Notice is hereby given in accordance with
G.S. 150B-21.2 that the NC Medical Board
intends to amend rule(s) cited as 21 NCAC
32R.0101-.0104.
Notice of Rule-making Proceedings was
published in the Register on August 2,
1999.
Proposed Effective Date: January 1, 2001
A Public Hearing will be conducted at
3:00 p.m. on March 3, 2000, at the NC
Medical Board, 1201 Front Street, Suite
100, Raleigh, NC 27609.
Comment Procedures: Written comments
will be accepted until close of business
March 16, 2000. Any interested person may
submit written comments on the proposed
rules by mailing the comments to Helen
Diane Meehleim, PO Box 20007, Raleigh,
NC 27619.
PROPOSAL
TITLE 21 CHAPTER 32 NORTH
CAROLINA MEDICAL BOARD
SUBCHAPTER 32R - CONTINU-ING
MEDICAL EDUCATION
(CME) REQUIREMENTS
.0101 CONTINUING MEDICAL EDU-CATION
(CME) REQUIRED
(a) CME is defined as knowledge and
skills generally recognized and accepted by
the profession as within the basic medical
sciences, the discipline of clinical medicine,
and the provision of healthcare to the public.
CME should maintain, develop, or improve
the physician’s knowledge, skills, profession-al
performance and relationships which
physicians use to provide services for their
patients, their practice, the public, or the
profession.
(b) Each person licensed to practice med-icine
in the State of North Carolina shall
complete no less than 150 hours of practice
relevant CME every three years in order to
enhance current medical competence, per-formance
or patient care outcome. At least
60 hours shall be in the educational
provider-initiated category as defined in
Rule .0102 of this Subchapter. The remain-ing
hours, if any, shall be in the physician-initiated
category as defined in Rule .0102
of this Subchapter. General medical reading
is not applicable to physician-initiated CME.
(c) The three year period described in
paragraph (b) above shall run from the
physician’s birthday beginning in the year
2001 or the first birthday following initial
licensure.
.0102 APPROVED CATEGORIES OF
CME
The following are the approved categories
of CME
(1) Physician-Initiated CME:
(a) Practice based self-study
(b) Colleague Consultations
(c) Office based outcomes research
(d) Study initiated by
patient inquiries
(e) Study of community
health problems
(f) Successful Specialty Board
Exam for certification or
recertification
(g) Teaching (professional,
patient/public health)
(h) Mentoring
(i) Morbidity and Mortality
(M&M) conference
(j) Journal clubs
(k) Creation of generic patient care
pathways and guidelines
(l) Competency Assessment
(2) Educational Provider-Initiated
CME: All education offered by
institutions or organizations accred-ited
by the Accreditation Council
on Continuing Medical Education
(ACCME) and reciprocating orga-nizations
or American Osteopathic
Association (AOA))
(a) Formal courses
(b) Scientific/clinical presentations,
or publications;
(c) Enduring Material
(Audio-Video);
(d) Skill development.
.0103 EXCEPTIONS
A licensee currently enrolled in an AOA or
Graduate Medical Education (ACGME)
accredited graduate medical education pro-gram
is exempt from the requirements of
Rule .0101 of this Section.
.0104 REPORTING
At the time of annual registration imme-diately
following the CME reporting period,
each Licensee shall report on the Board’s
annual registration form the number of
hours of practice-relevant CME obtained in
compliance with section .0101 of this
Subchapter. Records documenting CME
hours must be documented by categories for
six consecutive years and may be inspected
by the Board or its agents. u
NORTH CAROLINA
MEDICAL BOARD
SEEKS MEDICAL
COORDINATOR
The North Carolina Medical Board is
recruiting to fill a vacancy in the staff posi-tion
of Medical Coordinator. The physician
filling this position will review, evaluate, and
make recommendations to the Board about
reports concerning the conduct and/or per-formance
of physicians licensed to practice
medicine in North Carolina.
Any physician interested in being consid-ered
for the full time position of Medical
Coordinator must hold a full and unrestrict-ed
North Carolina medical license and
should submit a curriculum vitae to:
Mr Andrew Watry,
Executive Director, NC Medical Board
PO Box 20007
Raleigh, NC 27619
or
info@ncmedboard.org.
All inquiries regarding this position
should be made in writing and be directed to
Mr Watry at either of the addresses above.
Application deadline is March 15, 2000.
No. 4 1999 9
becoming more self-contained (less in need
of outside help) in doing so. Ameringer
describes this as a “change [in] focus from
guarding the gates to minding the store.”
Boards also have become more consumer-information
oriented, if only slightly.
Ameringer posits that medical boards
have been apart from rather than a part of
professional self-regulation of physicians.
The state and local medical societies had, in
the past, regulated the profession, if only
loosely, with the boards standing watch to
ensure the societies’ ability to do so. Part of
the reason this was so stems from differences
between the model of decision-making
employed by medical professionals and that
used by government agencies. Physicians
prefer “collegiality, informality, and confi-dentiality,”
leaving them with “independent
judgment and freedom from outside con-trol.”
Boards, obtaining their power from
governments, use a bureaucratic model,
“stressing hierarchy, formality, and account-ability.”
“Physicians [,therefore,] feared gov-ernmental
control of the disciplinary
process,” and, rather than embracing med-ical
board involvement in the disciplinary
process as professional self-regulation,
fought it. As a result, boards, rather than
being the profession’s chief (or, at least, last)
line of self-regulation, are a compromise
between self-regulation and government,
“temper[ing] bureaucracy with professional-ism,
discipline with rehabilitation, and dis-closure
with confidentiality.” Ameringer
concludes by cautioning that medical boards
are at risk of losing their relevance to private
enterprises providing medical care.
Though the author obviously draws heav-ily
on his experience with and direct obser-vation
of the Maryland board while he was
an assistant attorney general, the book is far
broader in scope, spanning two centuries of
history and the entire nation. It is well and
thoroughly researched, providing great force
to Ameringer’s arguments and valuable
guidance to readers who would explore the
subject in more depth. Those who want to
understand the forces that shaped and are
shaping state medical boards, and those who
want to consider what the near future may
bring, must read this book. u
Books about state medical boards are few.
[Of some note, though dated, are R.H.
Shryock, Medical Licensing in America:
1650-1965, The Johns Hopkins University
Press, 1967; R.C. Derbyshire, Medical
Licensure and Discipline in the United States,
The Johns Hopkins University Press, 1969;
W.O. Morris, Revocation of Professional
Licenses by Governmental Agencies, The
Michie Company, 1984.] When one comes
along, those interested in the subject matter
have high hopes. State Medical Boards and
the Politics of Public Protection, by Carl F.
Ameringer does not disappoint. Clearly
written, well presented, extensively annotat-ed,
and reasonably indexed, this book traces
the political forces that have shaped medical
boards in the United States from their incep-tion
to the present.
Ameringer begins by noting that the med-ical
profession secured the establishment of
medical boards principally to “protect the
public and the integrity of the medical pro-fession”
by defending the profession’s bor-ders
against pretenders or irregulars. For
most of their existence, medical boards have
focused outwardly, emphasizing licensing
over discipline, controlling entry to the pro-fession,
but doing little, if anything, to
police those already admitted. This latter
function was left to the local medical com-munities,
which often did little and, even at
their most vigorous, acted only informally
by boycott or the like.
—————————————————-
State Medical Boards and the Politics of Public
Protection
Carl F. Ameringer
The Johns Hopkins University Press,
Baltimore & London, 1999
176 pages (notes and index), $39.95 cloth
(ISBN 0-8018-5987-5)
—————————————————
Pressures mounted, including malpractice
litigation, organized public criticism, and
increasing concern over costs. Medical
boards, sometimes only begrudgingly, and
only in the last couple of decades, became
more active. They began involving them-selves
more in disciplining licensees and
Identification Badges
Required as of
October 1, 1999
During its 1999 session, the General
Assembly amended Chapter 90 of the
General Statutes by adding a new article,
Article 37, to require health care provider
identification. The new article is presented
below. It became effective on October 1,
1999.
ARTICLE 37
Health Care Practitioner Identification
§90-640. Identification badges
required.
(a) For purposes of this section, “health
care practitioner” means an individ-ual
who is licensed, certified, or regis-tered
to engage in the practice of
medicine, nursing, dentistry, pharma-cy,
or any related occupation involv-ing
the direct provision of health care
to patients.
(b)When providing health care to a
patient, a health care practitioner
shall wear a badge or other form of
identification displaying in readily
visible type the individual’s name and
the license, certification, or registra-tion
held by the practitioner. If the
identity of the individual’s license,
certification, or registration is com-monly
expressed by an abbreviation
rather than by full title, that abbrevi-ation
may be used on the badge or
other identification.
(c) The badge or other form of identifi-cation
is not required to be worn if
the patient is being seen in the health
care practitioner’s office and the
name and license of the practitioner
can be readily determined by the
patient from a posted license, a sign
in the office, a brochure provided to
patients, or otherwise.
(d) Each licensing board or other regula-tory
authority for health care practi-tioners
may adopt rules for exemp-tions
from wearing a badge or other
form of identification, or for allowing
use of the practitioner’s first name
only, when necessary for the health
care practitioner’s safety or for thera-peutic
concerns.
(e) Violation of this section is a ground
for disciplinary action against the
health care practitioner by the practi-tioner’s
licensing board or other reg-ulatory
authority. u
REVIEW
State Medical Boards and the Politics of Public
Protection
James A. Wilson, JD
Director, NCMB Legal Department
10 NCMB Forum
Preamble
The principles of professionalism and performance expressed in the posi-tion
statements of the North Carolina Medical Board apply to all persons
licensed and/or approved by the Board to render medical care at any level.
The words “physician” and “doctor” as used in the position statements of
the North Carolina Medical Board refer to persons who are MDs or DOs
licensed by the Board to practice medicine and surgery in North Carolina.
WHAT ARE THE POSITION STATEMENTS OF THE BOARD
AND TO WHOM DO THEY APPLY?
The North Carolina Medical Board’s Position Statements are interpretive
statements that attempt to define or explain the meaning of laws or rules
that govern the practice of physicians,* physician assistants, and nurse prac-titioners
in North Carolina, usually those relating to discipline. They also
set forth criteria or guidelines used by the Board’s staff in investigations and
in the prosecution or settlement of cases.
When considering the Board’s Position Statements, the following four
points should be kept in mind.
1. In its Position Statements, the Board attempts to articulate some of
the standards it believes applicable to the medical profession and to the
other health care professions it regulates. However, a Position
Statement should not be seen as the promulgation of a new standard
as of the date of issuance or amendment. Some Position Statements
are reminders of traditional, even millennia old, professional stan-dards,
or show how the Board might apply such standards today.
2. The Position Statements are not intended to be comprehensive or to
set out exhaustively every standard that might apply in every circum-stance.
Therefore, the absence of a Position Statement or a Position
Statement’s silence on certain matters should not be construed as the
lack of an enforceable standard.
3. The existence of a Position Statement should not necessarily be taken
as an indication of the Board’s enforcement priorities.
4. A lack of disciplinary actions to enforce a particular standard men-tioned
in a Position Statement should not be taken as an abandonment
of the principles set forth therein.
The Board will continue to decide each case before it on all the facts and
circumstances presented in the hearing, whether or not the issues have been
the subject of a Position Statement. The Board intends that the Position
Statements will reflect its philosophy on certain subjects and give licensees
some guidance for avoiding Board scrutiny. The principles of professional-ism
and performance expressed in the Position Statements apply to all per-sons
licensed and/or approved by the Board to render medical care at any
level.
*The words “physician” and “doctor” as used in the Position Statements
refer to persons who are MDs or DOs licensed by the Board to practice
medicine and surgery in North Carolina.
(Adopted 11/1999)
THE PHYSICIAN-PATIENT RELATIONSHIP
The North Carolina Medical Board recognizes the movement toward
restructuring the delivery of health care and the significant needs that moti-vate
that movement. The resulting changes are providing a wider range and
variety of health care delivery options to the public. Notwithstanding these
developments in health care delivery, the duty of the physician remains the
same: to provide competent, compassionate, and economically prudent care
to all his or her patients. Whatever the health care setting, the Board holds
that the physician’s fundamental relationship is always with the patient, just
as the Board’s relationship is always with the individual physician. Having
assumed care of a patient, the physician may not neglect that patient nor fail
for any reason to prescribe the full care that patient requires in accord with
the standards of acceptable medical practice. Further, it is the Board’s posi-tion
that it is unethical for a physician to allow financial incentives or con-tractual
ties of any kind to adversely affect his or her medical judgment or
patient care. Therefore, it is the position of the North Carolina Medical
Board that any act by a physician that violates or may violate the trust a
patient places in the physician places the relationship between physician and
patient at risk. This is true whether such an act is entirely self-determined
or the result of the physician’s contractual association with a health care
entity. The Board believes the interests and health of the people of North
Carolina are best served when the physician-patient relationship remains
inviolate. The physician who puts the physician-patient relationship at risk
also puts his or her relationship with the Board in jeopardy.
Elements of the Physician-Patient Relationship
The North Carolina Medical Board licenses physicians as a part of regu-lating
the practice of medicine in this state. Receiving a license to practice
medicine grants the physician privileges and imposes great responsibilities.
The people of North Carolina expect a licensed physician to be competent
and worthy of their trust. As patients, they come to the physician in a vul-nerable
condition, believing the physician has knowledge and skill that will
be used for their benefit.
Patient trust is fundamental to the relationship thus established. It
requires that
n there be adequate communication between the physician and the
patient;
n there be no conflict of interest between the patient and the physician
or third parties;
n intimate details of the patient’s life shared with the physician be held
in confidence;
n the physician maintain professional knowledge and skills;
n there be respect for the patient’s autonomy;
n the physician be compassionate;
Table of Contents
What are the Position Statements of the Board and
to Whom Do They Apply? .......................................................10
The Physician-Patient Relationship ..................................................10
Documentation of the Physician-Patient Relationship......................11
Medical Record Documentation ......................................................11
Access to Physician Records.............................................................11
Retention of Medical Records..........................................................12
Departures from or Closings of Medical Practices............................12
The Retired Physician......................................................................12
Advance Directives and Patient Autonomy ......................................13
Availability of Physicians After Hours..............................................13
Guidelines for Avoiding Misunderstandings During
Physical Examinations...............................................................13
Sexual Exploitation of Patients.........................................................13
Contact With Patients Before Prescribing.........................................14
Writing of Prescriptions ...................................................................14
Treatment of and Prescribing for Family Members...........................14
The Use of Anorectics in Treatment of Obesity ...............................14
Prescribing Legend or Controlled Substances for Other Than
Valid Medical or Therapeutic Purposes, with Particular
Reference to Substances or Preparations with
Anabolic Properties ...................................................................14
Management of Chronic Non-Malignant Pain .................................14
End-of-Life Responsibilities and Palliative Care ...............................15
(Medical, Nursing, Pharmacy Boards: Joint Statement on
Pain Management in End-of-Life Care).....................................15
Laser Surgery ..................................................................................16
Ophthalmologists: Care of Cataract Patients....................................16
HIV/HBV Infected Health Care Workers........................................17
Professional Obligation to Report Incompetence,
Impairment, and Unethical Conduct.........................................17
Continuing Medical Education ........................................................17
Fee Splitting ....................................................................................17
Unethical Agreements in Complaint Settlements .............................17
Position Statements of the North Carolina Medical Board
No. 4 1999 11
n the physician be an advocate for needed medical care, even at the expense
of the physician’s personal interests; and
n the physician provide neither more nor less than the medical problem
requires.
The Board believes the interests and health of the people of North Carolina
are best served when the physician-patient relationship, founded on patient
trust, is considered sacred, and when the elements crucial to that relationship
and to that trust — communication, patient primacy, confidentiality, compe-tence,
patient autonomy, compassion, selflessness, and appropriate care — are
foremost in the hearts, minds, and actions of the physicians licensed by the
Board.
This same fundamental physician-patient relationship also applies to mid-level
health care providers such as physician assistants and nurse practitioners
in all practice settings.
Termination of the Physician-Patient Relationship
The Board recognizes the physician’s right to choose patients and to termi-nate
the professional relationship with them when he or she believes it is best
to do so. That being understood, the Board maintains that termination of the
physician-patient relationship must be done in compliance with the physician’s
obligation to support continuity of care for the patient. The decision to ter-minate
the relationship must be made by the physician personally. Further, ter-mination
must be accomplished by appropriate written notice given by the
physician to the patient, the relatives, or the legally responsible parties suffi-ciently
far in advance (at least 30 days) to allow other medical care to be
secured. Should the physician be a member of a group, the notice of termi-nation
must state clearly whether the termination involves only the individual
physician or includes other members of the group. In the latter case, those
members of the group joining in the termination must be designated.
(Adopted 7/1995)
(Amended 7/1998, 1/2000)
DOCUMENTATION OF THE PHYSICIAN-PATIENT
RELATIONSHIP*
It is the position of the North Carolina Medical Board that when a physi-cian-
patient relationship is established, it should be documented by medical
records, which should contain, at a minimum, the following:
1. an appropriate history and physical and/or mental examination for the
patient’s chief complaint relevant to the physician’s specialty;
2. results of diagnostic tests (when indicated);
3. a working diagnosis;
4. notes on treatment(s) undertaken;
5. a record by date of all prescriptions for drugs, with names of medications,
strengths, dosages, quantity, and number of refills; and
6. a record of billings.
*See also position statement on Medical Record Documentation.
(Adopted 5/1991)
(Amended 5/1996)
MEDICAL RECORD DOCUMENTATION
p The North Carolina Medical Board takes the position that physicians and
physician extenders should maintain accurate patient care records of history,
physical findings, assessments of findings, and the plan for treatment. The
Board recommends the Problem Oriented Medical Record method known as
SOAP (developed by Lawrence Weed).
p SOAP charting is a schematic recording of facts and information. The S
refers to “subjective information” (patient history and testimony about feel-ings).
The O refers to objective material and measurable data (height, weight,
respiration rate, temperature, and all examination findings). The A is the
assessment of the subjective and objective material that can be the diagnosis
but is always the total impression formed by the care provided after review of
all materials gathered. And finally, the P is the treatment plan presented in suf-ficient
detail to allow another care provider to follow the plan to completion.
The plan should include a follow-up schedule.
p Such a chronological document
n records pertinent facts about an individual’s health and wellness;
n enables the treating care provider to plan and evaluate treatments or
interventions;
n enhances communication between professionals, assuring the patient
optimum continuity of care;
n assists both patient and physician to communicate to third party partici-pants;
n allows the physician to develop an ongoing quality assurance program;
n provides a legal document to verify the delivery of care; and
n is available as a source of clinical data for research and education.
p Certain items should appear in the medical record as a matter of course:
n the purpose of the patient encounter;
n the assessment of patient condition;
n the services delivered—in full detail;
n the rationale for the requirement of any support services;
n the results of therapies or treatments;
n the plan for continued care;
n whether or not informed consent was obtained; and, finally,
n that the delivered services were appropriate for the condition of the
patient.
p The record should be legible. When the care giver will not write legibly,
notes should be dictated, transcribed, reviewed, and signed within reasonable
time. Signature, date, and time should also be legible. All therapies should be
documented as to indications, method of delivery, and response of the patient.
Special instructions given to other care givers or the patient should be docu-mented:
Who received the instructions and did they appear to understand
them?
p All drug therapies should be named, with dosage instructions and indica-tion
of refill limits. All medications a patient receives from all sources should
be inventoried and listed to include the method by which the patient under-stands
they are to be taken. Any refill prescription by phone should be record-ed
in full detail.
p The physician needs and the patient deserves clear and complete documen-tation.
(Adopted 5/1994)
(Amended 5/1996)
ACCESS TO PHYSICIAN RECORDS
p A physician’s policies and practices relating to medical records should be
designed to benefit the health and welfare of patients, whether current or past,
and should facilitate the transfer of clear and reliable information about a
patient’s care when such a transfer is requested by the patient or anyone autho-rized
by law to act on the patient’s behalf.
It is the position of the North Carolina Medical Board that notes made by
a physician in the course of diagnosing and treating patients are primarily for
the physician’s use and are therefore the property of that physician. Moreover,
the resulting record is a confidential document and should only be released
with proper written consent of the patient. Each physician has a duty on the
request of a patient to release a copy or a summary of the record in a timely
manner to the patient or anyone the patient designates. If a summary is pro-vided,
it should include all the information and data necessary to allow conti-nuity
of care by another physician.
The physician may charge a reasonable fee for the preparation and/or the
photocopying of the materials. To assist in avoiding misunderstandings, and
for a reasonable fee, the physician should be willing to review the materials
with the patient at the patient’s request. Materials should not be held because
an account is overdue or a bill is owed.
Should it be the physician’s policy not to include in either the copied or the
summarized record those materials that were provided by other physicians
regarding the patient’s former or current care, he or she should advise the
patient of that fact and of ways those materials might be obtained.
12 NCMB Forum
p Should it be the physician’s policy to complete insurance or other forms for
established patients, it is the position of the Board that the physician should
complete those forms in a timely manner. If a form is simple, the physician
should perform this task for no fee. If a form is complex, the physician may
charge a reasonable fee.
p To prevent misunderstandings, the physician’s policies about providing
copies or summaries of patient records and about completing forms should be
made available in writing to patients when the physician-patient relationship
begins.
(Adopted 11/1993)
(Amended 5/1996)
(Amended 9/1997)
RETENTION OF MEDICAL RECORDS
n The North Carolina Medical Board supports and adopts the following lan-guage
of Section 7.05 of the American Medical Association’s current Code of
Medical Ethics regarding the retention of medical records by physicians.
7.05: Retention of Medical Records - Physicians have an obligation to retain
patient records which may reasonably be of value to a patient. The following
guidelines are offered to assist physicians in meeting their ethical and legal
obligations:
(1) Medical considerations are the primary basis for deciding how long to
retain medical records. For example, operative notes and chemothera-py
records should always be part of the patient’s chart. In deciding
whether to keep certain parts of the record, an appropriate criterion is
whether a physician would want the information if he or she were see-ing
the patient for the first time.
(2) If a particular record no longer needs to be kept for medical reasons, the
physician should check state laws to see if there is a requirement that
records be kept for a minimum length of time. Most states will not have
such a provision. If they do, it will be part of the statutory code or state
licensing board.
(3) In all cases, medical records should be kept for atleast as long as the
length of time of the statute of limitations for medical malpractice
claims. The statute of limitations may be three or more years, depend-ing
on the state law. State medical associations and insurance carriers
are the best resources for this information.
(4) Whatever the statute of limitations, a physician should measure time
from the last professional contact with the patient.
(5) If a patient is a minor, the statute of limitations for medical malpractice
claims may not apply until the patient reaches the age of majority.
(6) Immunization records always must be kept.
(7) The records of any patient covered by Medicare or Medicaid must be
kept at least five years.
(8) In order to preserve confidentiality when discarding old records, all doc-uments
should be destroyed.
(9) Before discarding old records, patients should be given an opportunity
to claim the records or have them sent to another physician, if it is fea-sible
to give them the opportunity.
............................
Please Note:
a. North Carolina has no statute relating specifically to the retention of med-ical
records.
b. Several North Carolina statutes relate to time limitations for the filing of
malpractice actions.
Legal advice should be sought regarding such limitations.
(Adopted 5/1998)
DEPARTURES FROM OR CLOSINGS OF MEDICAL PRACTICES
Departures from (when one or more physicians leave and others remain) or
closings of medical practices are trying times. They can be busy, emotional,
and stressful for all concerned: practitioners, staff, patients, and other parties
that may be involved. If mishandled, they can significantly disrupt continuity
of care. It is the position of the North Carlina Medical Board that during such
times practitioners and other parties that may be involved in such processes
must consider how their actions affect patients. In particular, practitioners and
other parties that may be involved have the following obligations.
p Permit Patient Choice
n It is the patient’s decision from whom to receive care. Therefore, it is the
responsibility of all practitioners and other parties that may be involved
to ensure that:
(1) patients are notified of changes in the practice, which is often done
by newspaper advertisement and by letters to patients currently
under care;
(2) patients are told how to access their medical records;
(3) patients are told how to reach any practitioner(s) remaining in prac-tice;
and
(4) patients clearly understand that the choice of a health care provider
is the patients’.
p Provide Continuity of Care
Practitioners continue to have obligations toward patients during and
after the departure from or closing of a medical practice. Except in case
of the death or other incapacity of the practitioner, practitioners may not
abandon a patient or abruptly withdraw from the care of a patient.
Therefore, patients should be given reasonable advance notice to allow
their securing other care. Good continuity of care includes preserving,
keeping confidential, and providing appropriate access to medical
records.* Also, good continuity of care may often include making appro-priate
referrals. The practitioner(s) and other parties that may be
involved should ensure the requirements for continuity of care are effec-tively
addressed.
No practitioner, group of practitioners, or other parties that may be
involved should interfere with the fulfillment of these obligations, nor should
practitioners put themselves in a position where they cannot be assured these
obligations can be met.
*The Board’s position statement on the Retention of Medical Records applies,
even when practices close permanently due to the retirement or death of the
practitioner.
(Adopted 1/2000)
THE RETIRED PHYSICIAN
n The retirement of a physician is defined by the North Carolina Medical
Board as the total and complete cessation of the practice of medicine and/or
surgery by the physician in any form or setting. According to the Board’s def-inition,
the retired physician is not required to maintain a currently registered
license and SHALL NOT:
l provide patient services;
l order tests or therapies;
l prescribe, dispense, or administer drugs;
l perform any other medical and/or surgical acts; or
l receive income from the provision of medical and/or surgical services
performed following retirement.
n The North Carolina Medical Board is aware that a number of physicians
consider themselves “retired,” but still hold a currently registered medical
license (full, volunteer, or limited) and provide professional medical and/or
surgical services to patients on a regular or occasional basis. Such physicians
customarily serve the needs of previous patients, friends, nursing home resi-dents,
free clinics, emergency rooms, community health programs, etc. The
Board commends those physicians for their willingness to continue service fol-lowing
“retirement,” but it recognizes such service is not the “complete cessa-tion
of the practice of medicine” and therefore must be joined with an undi-minished
awareness of professional responsibility. That responsibility means
that such physicians SHOULD:
l practice within their areas of professional competence;
l prepare and keep medical records in accord with good professional prac-tice;
and
No. 4 1999 13
l maintain their competence through an active continuing medical educa-tion
effort.
n The Board also reminds “retired” physicians with currently registered
licenses that all federal and state laws and rules relating to the practice of med-icine
and/or surgery apply to them, that the position statements of the Board
are as relevant to them as to physicians in full and regular practice, and that
they continue to be subject to the risks of liability for any medical and/or sur-gical
acts they perform.
(Adopted 1/1997)
ADVANCE DIRECTIVES AND PATIENT AUTONOMY
Advances in medical technology have given physicians the ability to prolong
the mechanics of life almost indefinitely. Because of this, physicians must be
aware that North Carolina law specifically recognizes the individual’s right to
a peaceful and natural death. NC Gen Stat 90-320 (a) (1993) reads:
The General Assembly recognizes as a matter of public policy that
an individual’s rights include the right to a peaceful and natural
death and that a patient or his representative has the fundamental
right to control the decisions relating to the rendering of his own
medical care, including the decision to have extraordinary means
withheld or withdrawn in instances of a terminal condition.
They must also be aware that North Carolina law empowers any adult indi-vidual
with understanding and capacity to make a Health Care Power of
Attorney [NC Gen Stat 32A-17 (1995)] and stipulates that, when a patient
lacks understanding or capacity to make or communicate health care decisions,
the instructions of a duly appointed health care agent are to be taken as those
of the patient unless evidence to the contrary is available [NC Gen Stat 32A-
24(b)(1995).
p It is the position of the North Carolina Medical Board that it is in the best
interest of the patient and of the physician/patient relationship to encourage
patients to complete documents that express their wishes for the kind of care
they desire at the end of their lives. Physicians should encourage their patients
to appoint a health care agent to act with the Health Care Power of Attorney
and to provide documentation of the appointment to the responsible physi-cian(
s). Further, physicians should provide full information to their patients
in order to enable those patients to make informed and intelligent decisions
prior to a terminal illness.
p It is also the position of the Board that physicians are ethically obligated to
follow the wishes of the terminally ill or incurable patient as expressed by and
properly documented in a declaration of a desire for a natural death.
p It is also the position of the Board that when the wishes of a patient are con-trary
to what a physician believes in good conscience to be appropriate care,
the physician may withdraw from the case once continuity of care is assured.
p It is also the position of the Board that withdrawal of life prolonging tech-nologies
is in no manner to be construed as permitting diminution of nursing
care, relief of pain, or any other care that may provide comfort for the patient.
(Adopted 7/1993)
(Amended 5/1996)
AVAILABILITY OF PHYSICIANS AFTER HOURS
p It is the position of the North Carolina Medical Board that once a physi-cian-
patient relationship is created, it is the duty of the physician to provide
care whenever it is needed or to assure that proper physician backup is avail-able
to take care of the patient during or outside normal office hours. If the
physician is not generally available outside normal office hours and does not
have an arrangement whereby another physician is available at such times, this
fact must be clearly communicated to the patient, verbally and in writing,
along with written instructions for securing care at such times.
p If the condition of the patient is such that the need for care at a time the
physician cannot be available is anticipated, the physician should consider
transfer of care to another physician who can be available when needed.
(Adopted 7/1993)
(Amended 5/1996)
GUIDELINES FOR AVOIDING MISUNDERSTANDINGS
DURING PHYSICAL EXAMINATIONS
It is the position of the North Carolina Medical Board that proper care and
sensitivity are needed during physical examinations to avoid misunderstand-ings
that could lead to charges of sexual misconduct against physicians. In
order to prevent such misunderstandings, the Board offers the following
guidelines.
1. Sensitivity to patient dignity should be considered by the physician when
undertaking a physical examination. The patient should be assured of
adequate auditory and visual privacy and should never be asked to dis-robe
in the presence of the physician. Examining rooms should be safe,
clean, and well maintained, and should be equipped with appropriate
furniture for examination and treatment. Gowns, sheets and/or other
appropriate apparel should be made available to protect patient dignity
and decrease embarrassment to the patient while a thorough and profes-sional
examination is conducted.
2. Whatever the sex of the patient, a third party should be readily available
at all times during a physical examination, and it is advisable that a third
party be present when the physician performs an examination of the
breast(s), genitalia, or rectum. When appropriate or when requested by
the patient, the physician should have a third party present throughout
the examination or at any given point during the examination.
3. The physician should individualize the approach to physical examina-tions
so that each patient’s apprehension, fear, and embarrassment are
diminished as much as possible. An explanation of the necessity of a
complete physical examination, the components of that examination,
and the purpose of disrobing may be necessary in order to minimize the
patient’s possible misunderstanding.
4. The physician and staff should exercise the same degree of professional-ism
and care when performing diagnostic procedures (eg, electro-car-diograms,
electromyograms, endoscopic procedures, and radiological
studies, etc), as well as during surgical procedures and postsurgical fol-low-
up examinations when the patient is in varying stages of conscious-ness.
5 The physician should be on the alert for suggestive or flirtatious behav-ior
or mannerisms on the part of the patient and should not permit a
compromising situation to develop.
(Adopted 5/1991)
(Amended 5/1993)
(Amended 5/1996)
SEXUAL EXPLOITATION OF PATIENTS
p It is the position of the North Carolina Medical Board that entering into a
sexual relationship with a patient, consensual or otherwise, is unprofessional
conduct and is grounds for the suspension or revocation of a physician’s
license. Such conduct is not tolerated.
p As with other disciplinary actions taken by the Board, Board action against
a medical licensee for sexual exploitation of a patient or patients is published
by the Board, the nature of the offense being clearly specified. It is also
released to the news media, to state and federal government, and to medical
and professional organizations.
p This position also applies to mid-level health care providers such as physi-cian
assistants, nurse practitioners, and EMTs authorized to perform medical
acts by the Board.
(Adopted 5/1991)
(Amended 4/1996)
14 NCMB Forum
CONTACT WITH PATIENTS BEFORE PRESCRIBING
p It is the position of the North Carolina Medical Board that prescribing
drugs to an individual the prescriber has not personally examined is usually
inappropriate. Before prescribing a drug, a physician should make an
informed medical judgment based on the circumstances of the situation and
on his or her training and experience. Ordinarily, this will require that the
physician personally perform an appropriate history and physical examination,
make a diagnosis, and formulate a therapeutic plan, a part of which might be
a prescription. This process must be documented appropriately.
p Prescribing for a patient whom the physician has not personally examined
may be suitable under certain circumstances. These may include admission
orders for a newly hospitalized patient, prescribing for a patient of another
physician for whom the prescriber is taking call, or continuing medication on
a short-term basis for a new patient prior to the patient’s first appointment.
Established patients may not require a new history and physical examination
for each new prescription, depending on good medical practice.
p It is the position of the Board that prescribing drugs to individuals the
physician has never met based solely on answers to a set of questions, as is
common in Internet or toll-free telephone prescribing, is inappropriate and
unprofessional.
[Adopted 11/1999]
WRITING OF PRESCRIPTIONS
p It is the position of the North Carolina Medical Board that prescriptions for
controlled substances or mind-altering chemicals should be written in ink or
indelible pencil or typewritten and should be manually signed by the practi-tioner
at the time of issuance. Quantities should be indicated in both numbers
AND words, eg, 30 (thirty). Such prescriptions must not be written on pre-signed
prescription blanks.
p Each prescription for a DEA controlled substance (2, 2N, 3, 3N, 4, and 5)
should be written on a separate prescription blank. Multiple medications may
appear on a single prescription blank only when none are DEA-controlled.
p No prescriptions, including those for controlled substances or mind-alter-ing
chemicals, should be issued for a patient in the absence of a documented
physician-patient relationship.
p No prescription for controlled substances or mind-altering chemicals should
be issued by a practitioner for his or her personal use.
p The practice of pre-signing prescriptions is unacceptable to the Board.
(Adopted 5/1991 and 9/1992)
(Amended 5/1996)
TREATMENT OF AND PRESCRIBING FOR FAMILY MEMBERS
p It is the position of the North Carolina Medical Board that, generally, a
physician should not prescribe for family members. Treating one’s family is
not illegal, but the Board wishes to remind physicians that such treatment and
prescribing practices may provide less than optimal care for a family member.
Written records of all therapies, including but not limited to writing prescrip-tions
for controlled substances and the medical indications for them, should be
maintained. The purpose of a medical record is to provide accurate informa-tion
regarding diagnosis and management of illness, but such record keeping
is too frequently neglected when a physician manages illness in his or her fam-ily.
The Board urges physicians to delegate the medical care of themselves and
their family members to one or more of their colleagues in order to preclude
involvement with governmental regulatory agencies that monitor physicians’
prescribing practices.
p Furthermore,
1. treatment of the immediate family members should be reserved for minor
illnesses, temporary or emergency situations;
2. appropriate consultations should be obtained for the management of
major or extended periods of illness;
3. any prescriptions issued should be within the scope of the physician’s
medical practice;
4. no Schedule 2, 3, or 4 controlled substances should be given or pre-scribed
for family members except in emergency situations;
5. appropriate records should be maintained for written prescriptions
and/or administration of any Schedule 2, 3, or 4 controlled substances.
(Adopted 5/1991)
(Amended 5/1996)
THE USE OF ANORECTICS IN TREATMENT OF OBESITY
p It is the position of the North Carolina Medical Board that under particu-lar
circumstances certain anorectic agents may have an adjunctive use in the
treatment of obesity. Good medical practice requires that such use be guided
by a written protocol that is based on published medical data and that patient
compliance and progress will be documented.
p It remains the policy of the Board that there is no place for the use of
amphetamines or methamphetamines in the treatment of obesity.
(Adopted 10/1987)
(Amended 3/1996)
PRESCRIBING LEGEND OR CONTROLLED SUBSTANCES FOR
OTHER THAN VALID MEDICAL OR THERAPEUTIC PURPOS-ES,
WITH PARTICULAR REFERENCE TO SUBSTANCES OR
PREPARATIONS WITH ANABOLIC PROPERTIES
General
p It is the position of the North Carolina Medical Board that prescribing any
controlled or legend substance for other than a valid medical or therapeutic
purpose is unprofessional conduct.
The physician shall complete and maintain a medical record that establish-es
the diagnosis, the basis for that diagnosis, the purpose and expected
response to therapeutic medications, and the plan for the use of medications
in treatment of the diagnosis.
The Board is not opposed to the use of innovative, creative therapeutics;
however, treatments not having a scientifically valid basis for use should be
studied under investigational protocols so as to assist in the establishment of
evidence-based, scientific validity for such treatments.
Substances/Preparations with Anabolic Properties
p The use of anabolic steroids, testosterone and its analogs, human growth
hormone, human chorionic gonadotrophin, other preparations with anabolic
properties, or autotransfusion in any form, to enhance athletic performance or
muscle development for cosmetic, nontherapeutic reasons, in the absence of an
established disease or deficiency state, is not a medically valid use of these med-ications.
The use of these medications under these conditions will subject the person
licensed by the Board to investigation and potential sanctions.
The Board recognizes that most anabolic steroid abuse occurs outside the
medical system. It wishes to emphasize the physician’s role as educator in pro-viding
information to individual patients and the community, and specifically
to high school and college athletes, as to the dangers inherent in the use of
these medications.
(Adopted 5/1998)
(Amended 7/1998)
MANAGEMENT OF CHRONIC NON-MALIGNANT PAIN
It has become increasingly apparent to physicians and their patients that the
use of effective pain management has not kept pace with other advances in
medical practice. There are several factors that have contributed to this. These
include a history of relatively low priority given pain management in our
health care system, the incomplete integration of current knowledge in med-ical
education and clinical practice, a sparsity of practitioners specifically
No. 4 1999 15
trained in pain management, and the fear of legal consequences when con-trolled
substances are used—fear shared by physician and patient. There are
three general categories of pain.
Acute Pain is associated with surgery, trauma and acute illness. It has
received its share of attention by physicians, its treatment by various
means is widely accepted by patients, and it has been addressed in guide-lines
issued by the Agency for Health Care Policy and Research of the
U.S. Department of Health and Human Services.
Cancer Pain has been receiving greater attention and more enlightened
treatment by physicians and patients, particularly since development of
the hospice movement. It has also been addressed in AHCPR guidelines.
Chronic Non-Malignant Pain is often difficult to diagnose, often
intractable, and often undertreated. It is the management of chronic
non-malignant pain on which the North Carolina Medical Board wishes
to focus attention in this position statement.
p The North Carolina Medical Board recognizes that many strategies exist for
treating chronic non-malignant pain. Because such pain may have many caus-es
and perpetuating factors, treatment will vary from behavioral and rehabili-tation
approaches to the use of a number of medications, including opioids.
Specialty groups in the field point out that most chronic non-malignant pain
is best managed in a coordinated way, using a number of strategies in concert.
Inadequate management of such pain is not uncommon, however, despite the
availability of safe and effective treatments.
The Board is aware that some physicians avoid prescribing controlled sub-stances
such as opioids in treating chronic non-malignant pain. While it does
not suggest those physicians abandon their reservations or professional judge-ment
about using opioids in such situations, neither does the Board wish to be
an obstacle to proper and effective management of chronic pain by physicians.
It should be understood that the Board recognizes opioids can be an appropriate treat-ment
for chronic pain.
p It is the position of the North Carolina Medical Board that effective man-agement
of chronic pain should include:
n thorough documentation of all aspects of the patient’s assessment and
care;
n a thorough history and physical examination, including a drug and pain
history;
n appropriate studies;
n a working diagnosis and treatment plan;
n a rationale for the treatment selected;
n education of the patient;
n clear understanding by the patient and physician of methods and goals of
treatment;
n a specific follow-up protocol, which must be adhered to;
n regular assessment of treatment efficacy;
n consultation with specialists in pain medicine, when warranted; and
n use of a multidisciplinary approach, when indicated.
p The Board expects physicians using controlled substances in the manage-ment
of chronic pain to be familiar with conditions such as:
n physical dependence;
n respiratory depression and other side effects;
n tolerance;
n addiction; and
n pseudo addiction.
There is an abundance of literature available on these topics and on the effec-tive
management of pain. The physician’s knowledge should be regularly
updated in these areas.
p No physician need fear reprisals from the Board for appropriately prescrib-ing,
as described above, even large amounts of controlled substances indefi-nitely
for chronic non-malignant pain.
p Nothing in this statement should be construed as advocating the imprudent
use of controlled substances.
(Adopted 9/1996)
END-OF-LIFE RESPONSIBILITIES AND PALLIATIVE CARE
Assuring Patients
p Death is part of life. When appropriate processes have determined that the
use of life-sustaining or invasive interventions will only prolong the dying
process, it is incumbent on physicians to accept death “not as a failure, but the
natural culmination of our lives.”* It is the position of the North Carolina
Medical Board that patients and their families should be assured of competent,
comprehensive palliative care at the end of their lives. Physicians should be
knowledgeable regarding effective and compassionate pain relief, and patients
and their families should be assured such relief will be provided.
Palliative Care
p There is no one definition of palliative care, but the Board accepts that
found in the Oxford Textbook of Palliative Medicine: “The study and man-agement
of patients with active, progressive, far advanced disease for whom
the prognosis is limited and the focus of care is the quality of life.” This is not
intended to exclude remissions and requires that the management of patients
be comprehensive, embracing the efforts of medical clinicians and of those
who provide psychosocial services, spiritual support, and hospice care. A
physician who provides palliative care, encompassing the full range of comfort
care, should assess his or her patient’s physical, psychological, and spiritual
conditions. Because of the overwhelming concern of patients about pain
relief, special attention should be given the effective assessment of pain. It is
particularly important that the physician frankly but sensitively discuss with
the patient and the family their concerns and choices at the end of life. As part
of this discussion, the physician should make clear that, in some cases, there
are inherent risks associated with effective pain relief in such situations.
Opioid Use
p The Board will assume opioid use in such patients is appropriate if the
responsible physician is familiar with and abides by acceptable medical guide-lines
regarding such use, is knowledgeable about effective and compassionate
pain relief, and maintains an appropriate medical record that details a pain
management plan. (See the Board’s position statement on the Management
of Chronic Non-Malignant Pain for an outline of what the Board expects of
physicians in the management of pain.) Because the Board is aware of the
inherent risks associated with effective pain relief in such situations, it will not
interpret their occurrence as subject to discipline by the Board.
Selected Guides
To assist physicians in meeting these responsibilities, the Board recommends
Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed (1996), Cancer
Pain Relief and Palliative Care (1990), Cancer Pain Relief and Palliative Care in
Children (1999), and Symptom Relief in Terminal Illness (1998), (World Health
Organization, Geneva); Management of Cancer Pain (1994), (Agency for
Health Care Policy and Research, Rockville, MD); Principles of Analgesic Use in
the Treatment of Acute Pain and Cancer Pain, 4th Edition (1999)(American
Pain Society, Glenview, IL); Hospice Care: A Physician’s Guide (1998)
(Hospice for the Carolinas, Raleigh); and the Oxford Textbook of Palliative
Medicine (1993) (Oxford Medical, Oxford).
(Adopted 10/1999)
*Steven A. Schroeder, MD, President, Robert Wood Johnson Foundation.
Joint Statement on Pain Management in End-of-Life Care (Adopted by
the North Carolina Medical, Nursing, and Pharmacy Boards)
p Through dialogue with members of the healthcare community and con-sumers,
a number of perceived regulatory barriers to adequate pain manage-ment
in end-of-life care have been expressed to the Boards of Medicine,
Nursing, and Pharmacy. The following statement attempts to address these
misperceptions by outlining practice expectations for physicians and other
healthcare professionals authorized to prescribe medications, as well as nurses
and pharmacists involved in this aspect of end-of-life care. The statement is
based on:
n the legal scope of practice for each of these licensed health professionals;
n professional collaboration and communication among health profession-als
providing palliative care; and
16 NCMB Forum
n a standard of care that assures on-going pain assessment, a therapeutic
plan for pain management interventions; and evidence of adequate symp-tom
management for the dying patient.
p It is the position of all three Boards that patients and their families should
be assured of competent, comprehensive palliative care at the end of their lives.
Physicians, nurses, and pharmacists should be knowledgeable regarding effec-tive
and compassionate pain relief, and patients and their families should be
assured such relief will be provided.
Because of the overwhelming concern of patients about pain relief, the
physician needs to give special attention to the effective assessment of pain. It
is particularly important that the physician frankly but sensitively discuss with
the patient and the family their concerns and choices at the end of life. As part
of this discussion, the physician should make clear that, in some end of life care
situations, there are inherent risks associated with effective pain relief. The
Medical Board will assume opioid use in such patients is appropriate if the
responsible physician is familiar with and abides by acceptable medical guide-lines
regarding such use, is knowledgeable about effective and compassionate
pain relief, and maintains an appropriate medical record that details a pain
management plan. Because the Board is aware of the inherent risks associat-ed
with effective pain relief in such situations, it will not interpret their occur-rence
as subject to discipline by the Board.
With regard to pharmacy practice, North Carolina has no quantity restric-tions
on dispensing controlled substances including those in Schedule II. This
is significant when utilizing the federal rule that allows the partial filling of
Schedule II prescriptions for up to 60 days. In these situations it would min-imize
expenses and unnecessary waste of drugs if the prescriber would note on
the prescription that the patient is terminally ill and specify the largest antici-pated
quantity that could be needed for the next two months. The pharma-cist
could then dispense smaller quantities of the prescription to meet the
patient’s needs up to the total quantity authorized. Government-approved
labeling for dosage level and frequency can be useful as guidance for patient
care. Health professionals may, on occasion, determine that higher levels are
justified in specific cases. However, these occasions would be exceptions to
general practice and would need to be properly documented to establish
informed consent of the patient and family.
Federal and state rules also allow the fax transmittal of an original prescrip-tion
for Schedule II drugs for hospice patients. If the prescriber notes the hos-pice
status of the patient on the faxed document, it serves as the original.
Pharmacy rules also allow the emergency refilling of prescriptions in Schedules
III, IV, and V. While this does not apply to Schedule II drugs, it can be use-ful
in situations where the patient is using drugs such as Vicodin for pain or
Xanax for anxiety.
The nurse is often the health professional most involved in on-going pain
assessment, implementing the prescribed pain management plan, evaluating
the patient’s response to such interventions and adjusting medication levels
based on patient status. In order to achieve adequate pain management, the
prescription must provide dosage ranges and frequency parameters within
which the nurse may adjust (titrate) medication in order to achieve adequate
pain control. Consistent with the licensee’s scope of practice, the RN or LPN
is accountable for implementing the pain management plan utilizing his/her
knowledge base and documented assessment of the patient’s needs. The nurse
has the authority to adjust medication levels within the dosage and frequency
ranges stipulated by the prescriber and according to the agency’s established
protocols. However, the nurse does not have the authority to change the med-ical
pain management plan. When adequate pain management is not achieved
under the currently prescribed treatment plan, the nurse is responsible for
reporting such findings to the prescriber and documenting this communica-tion.
Only the physician or other health professional with authority to pre-scribe
may change the medical pain management plan.
Communication and collaboration between members of the healthcare
team, and the patient and family are essential in achieving adequate pain man-agement
in end-of-life care. Within this interdisciplinary framework for end
of life care, effective pain management should include:
n thorough documentation of all aspects of the patient’s assessment and
care;
n a working diagnosis and therapeutic treatment plan including pharmaco-logic
and non-pharmacologic interventions;
n regular and documented evaluation of response to the interventions and,
as appropriate, revisions to the treatment plan;
n evidence of communication among care providers;
n education of the patient and family; and
n a clear understanding by the patient, the family and healthcare team of
the treatment goals.
It is important to remind health professionals that licensing boards hold
each licensee accountable for providing safe, effective care. Exercising this
standard of care requires the application of knowledge, skills, as well as ethical
principles focused on optimum patient care while taking all appropriate mea-sures
to relieve suffering. The healthcare team should give primary importance
to the expressed desires of the patient tempered by the judgement and legal
responsibilities of each licensed health professional as to what is in the patient’s
best interest.
(10/1999)
LASER SURGERY
p It is the position of the North Carolina Medical Board that the revision,
destruction, incision, or other structural alteration of human tissue using laser
technology is surgery.* Laser surgery should be performed only by a physi-cian
or by a licensed practitioner with appropriate medical training function-ing
under the supervision, preferably on-site, of a physician or by those cate-gories
of practitioners currently licensed by this state to perform surgical ser-vices.
Licensees should use only devices approved by the U.S. Food and Drug
Administration unless functioning under protocols approved by institutional
review boards. As with all new procedures, it is the licensee’s responsibility to
obtain adequate training and to make documentation of this training available
to the North Carolina Medical Board on request.
Lasers are employed in certain hair-removal procedures, as are various
devices that (1) manipulate and/or pulse light causing it to penetrate human
tissue and (2) are classified as “prescription” by the U.S. Food and Drug
Administration. Hair-removal procedures using such technologies should be
performed only by a physician or by a licensed practitioner with appropriate
medical training functioning under the supervision, preferably on-site, of a
physician who bears responsibility for those procedures.
*Definition of surgery as adopted by the NCMB, November 1998:
Surgery, which involves the revision, destruction, incision, or structural
alteration of human tissue performed using a variety of methods and instru-ments,
is a discipline that includes the operative and non-operative care of
individuals in need of such intervention, and demands pre-operative assess-ment,
judgment, technical skills, post-operative management, and follow
up.
(Adopted 7/1999)
(Amended 1/2000)
OPHTHALMOLOGISTS: CARE OF CATARACT PATIENTS
p The evaluation, diagnosis, and care of cataract surgical patients is primarily
the responsibility of the operating surgeon. The operating surgeon may not
delegate to optometrists, nurses, or anesthesiologists the responsibility of per-forming
an adequate preoperative examination. The surgeon must thorough-ly
examine each patient on whom he performs surgery prior to time for that
surgery. This thorough examination shall include a review of the patient’s his-tory
and an independent diagnosis by the operating surgeon of cataracts
requiring surgery. The operating surgeon shall have a detailed discussion with
each patient regarding the diagnosis and the nature of the cataract surgery,
advising the patient fully of the risks involved. All surgical decisions must be
made by the operating surgeon.
p Following surgery, the operating surgeon must perform the 24 hour post-operative
examination on every patient on whom he performs surgery, includ-ing
clear documentation of such examination in the patient record. In the case
of an emergency, the operating surgeon shall ensure that another ophthalmol-ogist
performs the 24 hour postoperative examination. Following the 24 hour
postoperative examination, the operating surgeon shall provide postoperative
care for each patient on whom he performs surgery until the healing process
is complete.
No. 4 1999 17
p It is not improper to involve non-physicians in postoperative care so long
as the operating surgeon maintains responsibility for the patient’s postopera-tive
care and examines the patient in the period following surgery to assess the
healing process and the long-term results.
p Even in the case of repetitive surgical procedures, a record should be kept
including detailed surgical notes describing each patient, his or her condition,
the procedures, methods, prostheses, results, prognosis, medication relative to
the surgery, and significant variations in each surgical procedure.
p The act of severing a suture following ophthalmologic surgery is a medical
act that can only be performed by the operating surgeon or by those health
care providers to whom this act may be legally delegated.
p It is improper to permit non-physicians to prescribe medication except as
provided by statute. In instances where the surgeon communicates and col-laborates
with an optometrist prescribing other than topical pharmaceutical
agents not used for the purpose of examining the eye, that communication and
collaboration must be contemporaneous with the issuance of any prescription
and specific for each patient.
(Adopted 9/1991)
HIV/HBV INFECTED HEALTH CARE WORKERS
The North Carolina Medical Board supports and adopts the North Carolina
Department of Environment, Health and Natural Resources Division of
Epidemiology’s rule for HIV and HBV Infected Health Care Workers
(T15A:19A.0207), and its rule for Infection Control in Health Care Settings
(T15A:19A.0206). It is the Board’s position that all licensees should be famil-iar
with the current requirements of those rules.
(Adopted 11/1992)
(Amended 5/1996)
PROFESSIONAL OBLIGATION TO REPORT INCOMPETENCE,
IMPAIRMENT, AND UNETHICAL CONDUCT
p It is the position of the North Carolina Medical Board that physicians have
a professional obligation to act when confronted with an impaired or incom-petent
colleague or one who has engaged in unethical conduct.
When appropriate, an offer of personal assistance to the colleague may be
the most compassionate and effective intervention. When this would not be
appropriate or sufficient to address the problem, physicians have a duty to
report the matter to the institution best positioned to deal with the problem.
For example, impaired physicians and physician assistants should be reported
to the North Carolina Physicians Health program. Incompetent physicians
should be reported to the clinical authority empowered to take appropriate
action. Physicians also may report to the North Carolina Medical Board, and
when there is no other institution reasonably likely to be able to deal with the
problem, this will be the only way of discharging the duty to report.
This duty is subordinate to the duty to maintain patient confidences. In
other words, when the colleague is a patient or when matters concerning a col-league
are brought to the physician’s attention by a patient, the physician must
give appropriate consideration to preserving the patient’s confidences in decid-ing
whether to report the colleague.
(Adopted 11/1998)
CONTINUING MEDICAL EDUCATION
p North Carolina physicians engaged in active clinical practice should obtain
regular, continuing medical education as a part of maintaining their compe-tence
to practice medicine with reasonable skill and safety.
p The North Carolina Medical Board strongly encourages its licensees who
are actively engaged in clinical practice to obtain and maintain documentation
of not less than one hundred fifty (150) hours of continuing medical educa-tion
every three years. The majority of these hours should be applicable to the
individual’s practice specialty.
(Adopted 5/1991)
(Amended 1/1992)
(Amended 5/1996)
FEE SPLITTING
p The North Carolina Medical Board endorses the AMA Code of Medical
Ethics Opinions 6.02, 6.03, and 6.04 condemning fee splitting. Fee splitting
may be receipt of money or something else of value in return for referrals or
remuneration from a drug or device manufacturer/distributor, a sales repre-sentative,
or another professional as an incentive for the use of that interested
party’s product.
p Except in instances permitted by law (NC Gen Stat 55B-14(c)), it is the
position of the Board that sharing profits between a non-physician or para-professional
and a physician partner on a percentage basis is also fee splitting
and is grounds for disciplinary action.
(Adopted 11/1993)
(Amended 5/1996)
UNETHICAL AGREEMENTS IN COMPLAINT SETTLEMENTS
It is the position of the North Carolina Medical Board that it is unethical for
a physician to settle any complaint if the settlement contains an agreement by
a patient not to complain or provide information to the Board.
(Adopted 11/1993)
(Amended 5/1996)
NORTH CAROLINA
MEDICAL BOARD SEEKS
MEDICAL
COORDINATOR
The North Carolina Medical Board is recruiting to
fill a vacancy in the staff position of Medical
Coordinator. The physician filling this position will
review, evaluate, and make recommendations to the
Board about reports concerning the conduct and/or
performance of physicians licensed to practice medi-cine
in North Carolina.
Any physician interested in being considered for the
full time position of Medical Coordinator must hold a
full and unrestricted North Carolina medical license
and should submit a curriculum vitae to:
Mr Andrew Watry,
Executive Director, North Carolina Medical Board
PO Box 20007
Raleigh, NC 27619
or
info@ncmedboard.org.
All inquiries regarding this position should be made
in writing and be directed to Mr Watry at either of the
addresses above. Application deadline is March 15,
2000.
18 NCMB Forum
ANNULMENTS
NONE
REVOCATIONS
POWELL, John Gary, MD
Location: Lynchburg, VA
DOB: 2/03/1939
License #: 0000-14750
Specialty: PD (as reported by physician)
Medical Ed: Duke University School of Medicine (1965)
Cause: On 3/09/1998, pursuant to a Consent Order with the Virginia
medical board, Dr Powell surrendered his license based on his
arrest for reproducing sexually explicit material that used or had
as a subject a person less than 18 years old, which is a Class 5
felony in Virginia.
Action: 8/04/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued: Dr Powell’s North Carolina license is revoked.
See Consent Orders:
MIJANOVICH, James Robert, MD
SUSPENSIONS
ANDERSON, Lorenzo James, Physician Assistant
Location: Greenville, SC
DOB: 10/30/1953
License #: 0001-02264
PA Education: Medical College of Georgia (1993)
Cause: Mr Anderson’s license to practice dentistry in Florida was
revoked by the dental board of that state on or about
10/14/1988; his dentistry license in Georgia was placed on pro-bation
for two years on or about 3/24/1989; in November 1990,
the Georgia dentistry board issued a Notice of Hearing on
charges concerning him; on 1/24/1991, he surrendered his den-tistry
license in Georgia; in November 1996, he applied for a PA
license in North Carolina; on his application form, he answered
“no” to questions asking if there had ever been disciplinary pro-ceedings
or investigations concerning him by governmental or
regulatory agencies, thus responding falsely so as to fraudulently
or deceptively obtain a license.
Action: 9/07/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued: Mr Anderson’s PA license is suspended. [See
also Consent Order of 10/27/1999 cited below.]
TANKSLEY, Marion Hollis, DO
Location: Hartfield, VA
DOB: 3/22/1937
License #: 0000-17192
Specialty: FP/AM (as reported by physician)
Medical Ed: Iowa College of Osteopathic Medicine (1968)
Cause: In May 1996, Dr Tanksley was convicted by General Court-
Martial at the Norfolk, VA, Naval Base of three violations of the
Uniform Code of Military Justice: while on active duty he failed
to obtain permission to work as a part-time civilian physician
from May through June 1994; with intent to deceive, he falsely
responded to a Personnel Security Questionnaire, to a Defense
Investigative Service Special Agent, to questions on a Personal
and Professional Information Sheet, to a DIS Special Agent as
part of an official statement, and to the president of the Navy
Physical Evaluation Board; in August 1993, he took indecent
liberties with a female under 16 years of age; in November 1993,
he wrongfully attempted to hinder a Navy investigation and to
intimidate witnesses; and in December 1993, he made false
statements under oath. These convictions were affirmed by the
U.S. Navy-Marine Corps Court of Criminal appeals in 1999. In
February 1997, the Virginia Board of Medicine, in consideration
of these convictions, suspended Dr Tanksley’s medical license,
the suspension being stayed on terms and conditions. In April,
1999, the Virginia Board terminated the terms and conditions
imposed on Dr Tanksley’s license and reinstated his license to full
and unrestricted status. In May 1998, the Composite State
Board of Medical Examiners of Georgia, acting in consideration
of the convictions, placed his medical license on indefinite pro-bation
with terms and conditions.
Action: 8/24/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued following a hearing before the North Carolina
Medical Board on July 22, 1999. Dr Tanksley’s medical license
is suspended indefinitely. All but 90 days of the suspension will
be stayed if, within 90 days, Dr Tanksley signs a Consent Order
in the form attached to this Order. The Consent Order would
reprimand Dr Tanksley and place terms and conditions on his
license.
See Consent Orders:
JUBERG, Breton Chester, MD
WASHINGTON, Clarence Joseph, III, MD
SUMMARY SUSPENSIONS
DECLERCK, Paul A., MD
Location: Kinston, NC (Lenoir Co)
DOB: 10/07/1947
License #: 0000-24240
Specialty: FP (as reported by physician)
Medical Ed: University of Brussels, Belgium (1975)
Cause: As alleged in the Notice of Charges and Allegations, it appears
to the Board that Dr DeClerck may be unable to practice medi-cine
with reasonable skill and safety by reason of illness, drunk-enness,
excessive use of alcohol, drugs, chemicals, or any other
type of materials or by reason of any physical or mental abnor-mality
within the meaning of the applicable law.
Action: 8/30/1999. Order of Summary Suspension of License issued,
effective September 2, 1999. [See also Surrender of 9/01/1999
cited below.]
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
August, September, October 1999
DEFINITIONS
PETERSON, William, MD
Location: Rutherfordton, NC (Rutherford Co)
DOB: 1/15/1949
License #: 0096-01432
Specialty: N/CN (as reported by physician)
Medical Ed: Hahnemann School of Medicine (1975)
Cause: Dr Peterson may be unable to practice medicine with reasonable
skill and safety by reason of illness, drunkenness, excessive use of
alcohol, drugs, chemicals, or any other type of material or by rea-son
of a physical or mental abnormality within the meaning of
the law.
Action: 8/02/1999. Order of Summary Suspension of License issued,
effective August 12, 1999. [Notice of Charges dated 8/02/1999
alleging inability to practice with reasonable skill and safety and
unresponsiveness to calls from the hospital while on call.]
WORIAX, Eric, Physician

Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
The Spirit of Collegiality.............................1
From the Executive Director:
Internet Prescribing....................................1
On the Necessity of Medical Chaperones .......4
NCMB Seeks Medical Coordinator................4
Two New Position Statements Adopted by
NCMB: Relate to Internet Prescribing
and Closing of Practice.............................5
What Are the Position Statements of the
NCMB and to Whom Do They Apply?....5
NCMB Adopts Position Statement on End-of-
Life Responsibilities and Palliative
Care, Joins Pharmacy and Nursing
Boards in Combined Statement................6
NCMB Amends Two Position Statements......7
President’s
Message
From the
Executive
Director
Wayne W. VonSeggen, PA-C Andrew W. Watry
No. 4 1999
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
The Spirit of Collegiality
After five years on the North Carolina
Medical Board, it is a special honor for me to
have been nominated and elected by my fel-low
Board members to be the president for
the coming year. At one time or another in
the past, most of us have wondered what we
would be doing when the year 2000 rolled
around. Years ago, when I became interest-ed
in a possible medical career, I would never
have guessed that I would come to this
unique position of responsibility.
I remember early in my life reading the
book The Brothers Mayo, which recounted
the lives of the great pioneer physicians and
surgeons, Will and Charles Mayo. Their
great skill as early American diagnosticians
and bold surgeons sparked the formation of
what is now known as the Mayo Clinic in
Rochester, Minnesota. I dreamed of enter-ing
the medical profession and somehow
contributing to the bettering of people’s
lives through application of medical knowl-edge
and entrepreneurial creativity. The
comradeship and team spirit that Will and
Charles Mayo seemed to have in augmenting
each other, and in building a system of
health care that would outlive them, pre-sented
a challenge for me and for lots of
other young people interested in getting into
the medical field.
I made the choice of entering into physi-cian
assistant training. I selected the
Bowman Gray Physician Assistant Program
here in Winston-Salem and graduated in
1977. Being a physician assistant has
brought me a sense of being able to help my
patients directly and to participate in the joy
of problem solving within medicine that I
had so deeply desired. I knew I had found
my niche in life. My twenty-two years prac-ticing
as a physician assistant here in North
Carolina have been very rewarding since
they have allowed me to work side-by-side
with physicians, other physician assistants,
nurse practitioners, and nurses. The team
concept of physician assistants working as
dependent practitioners with a physician, or
a group of physicians, requires constant
communication between team members in
Internet Prescribing
I am summarizing below key excerpts
from a solicitation we recently received
online through America On Line (AOL).
The solicitation was entitled, Special
Bulletin: Solicitation of Docs for Internet
Prescribing.
Hello. Pardon me for the random
intrusion. . . . I saw you online under
“physician” on AOL. We have set up a net-work
of doctors who are interested in help-ing
patients online with non-critical care pre-scriptions.
This is cutting-edge medical
practice. You are given the opportunity to
help many people at one time and your com-pensation
is very nice. . . . We have a strong
organization and refuse to dispense meds
unethically, or illegally as many organizations
have been doing on the Internet. . . .
Candidates must be able to prescribe med-ications
such as Propecia, Viagra, Merida
and Claritin. . . . Our goal is to increase the
amount of care offered to people who cannot
get to see a doctor and/or who are too
embarrassed to go talk about their erectile
dysfunction in person. NOTE: Doctors will
make up to $12,500 per month for script
approval. Here is how our system works:
patients seeking help will log into our sys-tem,
fill-out a detailed questionnaire which
will be forwarded to you, and then you will
have the option to approve or disapprove
their request. E-prescriptions will be for-warded
to our pharmacy and the medica-tions
will be sent. . . . There is an immediate
need for five doctors in each state. . . . They
will all come from various states, so those
wont [sic] all be for one doctor however the
script rate is $20 per approval. A single doc-tor
will likely approve 10-100 per day on the
average. These would take only a few min-utes
each to look over. You can do the math.
forum
continued on page 3
continued on page 2
Special Notice of Hearing and Comment
Period on Proposed Amendment
to Rules: NCMB Continuing Education
Requirements ...........................................8
NCMB Seeks Medical Coordinator................8
Review: State Medical Boards and the
Politics of Public Protection ..........................9
Identification Badges Required as of
October 1, 1999.......................................9
NCMB Position Statements .........................10
NCMB Seeks Medical Coordinator..............17
Board Actions: 8/1999-10/1999 ..................18
Board Calendar............................................23
Change of Address Form .............................24
Important Notice.........................................24
FOCUS ON
NCMB POSITION STATEMENTS
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. IV, No. 4, 1999
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Wayne W. VonSeggen, PA-C
President
Winston-Salem
Term expires
October 31, 2000
Elizabeth P. Kanof, MD
Vice President
Raleigh
Term expires
October 31, 1999
Walter J. Pories, MD
Secretary-Treasurer
Greenville
Term expires
October 31, 2000
Kenneth H. Chambers, MD
Charlotte
Term expires
October 31, 2001
John T. Dees, MD
Cary
Term expires
October 31, 2000
John W. Foust, MD
Charlotte
Term expires
October 31, 2000
Hector H. Henry, II, MD
Concord
Term expires
October 31, 1999
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2001
Paul Saperstein
Greensboro
Term expires
October 31, 2001
Charles E. Trado, MD
Hickory
Term expires
October 31, 1999
Martha K. Walston
Wilson
Term expires
October 31, 1999
Andrew W. Watry
Executive Director
Helen Diane Meelheim
Assistant Executive Director
Bryant D. Paris, Jr
Executive Director
Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Editorial Assistant
Jennifer L. Deyton
Mailing Address
Forum
NC Medical Board
PO Box 20007
Raleigh, NC 27619
Street Address
1201 Front Street
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.docboard.org/nc
E-Mail:
ncmedbrd@interpath.com
The Spirit of Collegiality
continued from page 1
order to deliver high quality health care ser-vices
to our patients.
My participation on the North Carolina
Medical Board since 1994 has provided me
a regulator’s view to see how the various
medical professions here in this state have
been able to build great opportunities for a
variety of medical professionals. Several
groups of health care providers have pro-gressed
significantly in this supportive envi-ronment.
Nurse practitioners have gained
the opportunity to develop true collabora-tive
practice agreements in which their
nursing and clinical management skills can
be used more effectively. The Board, in
cooperation with the Office of Emergency
Medical Services, has developed an excel-lent
system for our emergency medical per-sonnel
to be used to their maximal skill lev-els,
yet with a high degree of physician
involvement and support. Physicians in
training have been encouraged to be sensi-tive
to the dangers of overextending them-selves
during residencies, and to be alert for
early signs of substance abuse and impair-ment
even during their residency years.
Improvements in the legislative and reg-ulatory
climate here in North Carolina have
permitted physician assistants to be fully uti-lized
professionally. For those physicians or
groups of physicians who have incorporated
the use of physician assistants in their prac-tices,
mutual interdependence and respect
have provided each with positive reinforce-ment
that the MD-PA team is a great idea.
As increased recognition of the physician
assistant profession has matured, so have the
relationships of the North Carolina Medical
Board with the North Carolina Academy of
Physician Assistants and the North Carolina
Medical Society.
In my opinion, North Carolina possesses
an environment that has fostered the best
statutes and regulations for physician assis-tant
practice in the entire nation. Physician
assistants have been invited to be full mem-bers
of the North Carolina Medical Society
and can participate in the Society’s House of
Delegates through its “PA Section.” The
North Carolina Physicians Health Program
assists recovering physicians and physician
assistants. Continuing medical education
providers encourage CME training for
physicians and other members of the health
care team. Private, state, and federal
employers routinely include physician assis-tants
and nurse practitioners on their cost-effective
health care delivery teams in a vari-ety
of primary care and specialty practices.
Managed care systems now may include
physician assistants and nurse practitioners
in their provider bulletins. The General
Assembly has contributed to the permanent
representation of mid-level practitioners by
the addition of a full board member position
for “at least one physician assistant or nurse
practitioner” on the North Carolina Medical
Board.
For the Board to choose a non-physician
to hold a position as one of its officers speaks
volumes for the courage, the maturity, and
the comfort level of the current Board. The
friendship and sincere collegiality of the cur-rent
members of the Board have provided an
opportunity for me (and perhaps future
mid-level health care practitioners) to share
in the responsible governance of the medical
profession in this state. The growth of
respect and collegiality in North Carolina
between physicians and the PA/NP profes-sions
has blossomed into a beautiful situa-tion
that I hope could serve as a model in
many other states. Patients (the public) are
the clear winners when the medical team
functions cooperatively and efficiently with
professional respect for what each member
of that team can contribute.
I have been honored to follow Mr Paul
Saperstein, a public member of the Board, as
president. Mr Saperstein served and guided
the North Carolina Medical Board with
great distinction and excellent management
skills. He has been sensitive to the charge to
protect the public while properly regulating
the medical profession. The other members
of the Board constantly interact and provide
support in areas where a public member or a
physician assistant member may lack exper-tise.
The beauty of the functioning of the
Board is that the decisions and actions reflect
the wisdom, creativity, and sensitivity of all
its members, no matter who the officers may
be.
I look forward to this new year of service
on the Board, and I hope to be available to
all licensees of the Board. The North
Carolina Medical Board and our competent
staff hope to improve communications with
you even more, and to assure our citizens
that our concerted efforts will provide North
Carolinians with the best medical practice
environment in America for physicians,
physician assistants, nurse practitioners, and
EMS personnel. Our availability to you
through the Forum and electronic methods,
including Web page, e-mail, and state of
the art telephone system, shows our
determination to provide North Carolinians
with the best possible service. You may
contact me through the Board or via E-mail
at wvonseggen@aol.com. u
No. 4 1999 3
Internet Prescribing
continued from page 1
1-800-253-9653
North Carolina
Medical Board
It is projected that the number of people
using the Internet for health and medical
information will reach 30 million this year,
rising from 7.8 million in 1996. Part of the
attraction of the
Internet is the
fact that it is a
laissez-faire mar-ketplace.
That is
also part of the
problem when it
comes to pre-scription
med-ications.
The
Internet can be a
valuable source
of information.
However, it can
also be a place where prescription drugs can
be purchased without benefit of the signifi-cant
patient protection mechanisms devel-oped
in this country over the past century.
A recent article in the New England
Journal of Medicine highlights the problem
as it relates to sildenafil citrate (Viagra®).
The authors focused their survey on Web
sites offering direct sale of this drug to con-sumers.
Their findings: they identified 86
sites that offered to deliver sildenafil citrate
directly to consumers without a visit to a
physician. Only 27 sites specified that a
physician would review each questionnaire.
Their findings document that sildenafil cit-rate
is readily obtainable over the Internet
without the need for a visit to a physician
or review by a pharmacist. They conclude:
“the ability to buy drugs over the Internet
means that important safeguards intrinsic
to conventional prescribing and related to
the physician-patient relationship are
bypassed.” They recommend: “in the light
of our findings we believe that state licens-ing
boards for physicians and pharmacists
should move quickly to establish and
enforce guidelines for the involvement of
U.S. clinicians in prescribing drugs over the
Internet.”
Some of the vendors for Internet pre-scribing
are making a credible effort to
build patient protection mechanisms, such
as providing responsible physician over-sight
in the process. However, it is clear
that many sites are not providing such pro-tection.
It is equally clear that in spite of
whatever mechanisms are provided for
online physician consultation, it is far too
easy for a “patient” to dupe the prescribing
physician without a personal encounter.
In response to a question from a member
of the Medical Board, we ordered some
Viagra® online in this office. We filled out a
short questionnaire and took delivery of a
substance represented as Viagra® in less than
24 hours. It was delivered to our offices
along with our other mail. It was delivered
via Federal Express. Some may argue that
current regulation is excessive. However, we
have the following questions and we expect
that many consumers would have similar
questions.
l Was the substance Viagra®? It could
easily have been a sugar pill.
l Where had this substance been stored
and how had it been transported? If we
picked it up at a pharmacy, the pharma-cist
would be responsible for giving us
patient information, including informa-tion
about medications that should not
be taken with this drug. The pharma-cist
would be responsible for making
sure we do not get an outdated drug,
that it is in fact Viagra®, that it is in an
appropriately labeled package, and that
it is the result of a legitimate prescrip-tion.
None of those safeguards were in
place with the sample we received. In
fact, we can find no physician (MD or
DO) in the entire country who has the
name of the alleged physician whose
name appears on the bottle. We did
verify that he was not in North Carolina
and we forwarded the matter to appro-priate
enforcement authorities.
l How do we know whether this drug
was stored in somebody’s hot attic or
car trunk or whether it was legitimately
stored and handled by an appropriately
licensed, trained pharmacist?
l Suppose a complication arises? Is that
anonymous person authorizing the pre-scription
at the other end of the Web
site available to help with local medical
care in the event of such a complica-tion?
l What would prevent a 16-year-old from
gaming the questionnaire to get and
perhaps sell the drug?
These and other issues are a matter of con-cern
to many, if not most of the medical
boards in this country. As Armstrong,
Schwartz, et al, noted in their NEJM article,
it is appropriate for state medical and phar-macy
boards to move quickly to establish
and enforce guidelines for the involvement
of U.S. clinicians in prescribing drugs over
the Internet.
Your North Carolina Medical Board has
issued a position statement entitled Contact
With Patients Before Prescribing that deals
with this issue directly. This position state-ment
may be found in this number of the
Forum and on our Web site. It gives physi-cians
holding North Carolina licenses guid-ance
that leads
to the following
statement: “It
is the position
of the Board
that prescribing
drugs to indi-viduals
the
physician has
never met based
solely on
answers to a set
of questions, as
is common in
Internet or toll-free telephone prescribing, is
inappropriate and unprofessional.”
The Federation of State Medical Boards is
formulating recommendations to all of the
licensing boards in the United States on this
issue and these recommendations should be
available shortly. The U.S. Congress has
asked the General Accounting Office to con-duct
a study of online pharmacies and online
physician prescribing practices; and
President Clinton has proposed giving the
Food and Drug Administration new powers
to review and certify drug-dispensing Web
sites. We will advise you of any significant
developments at the federal level.
In conclusion, the Internet is nothing
more than a much improved mechanism for
communicating information. No one on
our Medical Board or in the field of medical
regulation, to my knowledge, is interested in
shooting the messenger. The principal con-cern
is that the Internet also provides a
mechanism for circumventing time-tested
safeguards when it comes to prescribing
dangerous drugs.
Imagine the pub-lic
harm if phen-fen
had been as
readily available
on the Internet
as Viagra® is
now.
The medical
boards in this
country are very
diverse, but they
all have one
thing clearly in common: a legislative man-date
to protect the public. The North
Carolina Medical Board takes this regulatory
responsibility seriously; it does not want to
be in the position of waiting until people are
harmed before it reacts. That was the dri-ving
force for the development of its recent
position statement on the subject. We will
try to keep you updated on developments in
this important area. u
“It is appropriate for
state medical and
pharmacy boards to
move quickly to
establish and enforce
guidelines for the
involvement of U.S.
clinicians in pre-scribing
drugs over
the Internet.”
“It is projected that
the number of peo-ple
using the
Internet for health
and medical infor-mation
will reach
30 million this
year, rising from
7.8 million in
1996.”
“The principal con-cern
is that the
Internet also pro-vides
a mechanism
for circumventing
time-tested safe-guards
when it
comes to prescribing
dangerous drugs.”
4 NCMB Forum
The need for chaperones during gyneco-logic
examinations has been of particular
interest to the American Society of Forensic
Obstetricians and Gynecologists (ASFOG)
for a number of years, evidenced by our
Newsletter’s addressing the issue on multiple
occasions with original articles, letters to the
editor, and reprints of other relevant research
and opinions.1-9 The American College of
Obstetricians and Gynecologists (ACOG)
has also addressed the issue in multiple pub-lications.
10-14
All the above agree with a recent article in
the North Carolina Medical Board’s Forum
[Vol. IV, No. 3 (1999), p.11, Don’t
Underestimate the Importance of
Chaperones] recommending the use of
chaperones when physicians examine partial-ly
or completely disrobed patients of the
opposite sex. ASFOG goes even further by
recommending use of an employee chaper-one,
preferably of the same sex and prefer-ence
(if known) as the patient, for all breast,
genital, or rectal examinations regardless of
the sex or preference of patient or physician.
Another recent article in a major peer-reviewed
medical journal may, however, be
construed by some as downplaying the
importance of chaperones.15 It reports
results of a survey of 67 U.S. state medical
and osteopathic licensing boards on their
policies, opinions, positions, or laws regard-ing
the use of chaperones in gynecologic
examinations. The authors observe there
was “no consensus among state medical
boards on the use of chaperones,” with
almost ten percent (6) failing to respond to
the authors’ queries despite three formal
requests. Over half those replying had no
position on the use of chaperones, possibly
indicating chaperones are unnecessary. The
authors’ closing remark, “it is important to
give physicians direction on this issue,” is
certainly an understatement.
For years, ACOG’s publications have
advocated chaperone use with comments
ranging from “can confer benefits”10 and
“advisable”12 to “should be present,”13
“strongly recommended,”11 and “is a must.”14
Our ASFOG Newsletter has supported simi-lar
recommendations and opinions, such as
“require(d),”1 “never. . .without,”2 “need-ed,”
4 “nurse should be present whenever a
pelvic examination is performed,” 5 and
“require(d).”8
Although no regulatory body or national
medical organization requires or probably
ever will require their routine use during
COMMENTARY
On the Necessity of Medical Chaperones
William D. Daniel, MD, Executive Director
American Society of Forensic Obstetricians and Gynecologists
breast, genital, or rectal examinations, chap-erones
are the only available defense for
patients against the relatively rare physician’s
sexual improprieties and for physicians
against the equally rare patient’s unsubstan-tiated
charges of sexual impropriety or even
assault. Considering the stakes, we should
just do it!
NOTES
1. L. Iffy, “Must Female Physicians Have
Chaperones?” OB-GYN Malpractice Prevention 1,
No.7 (1994): 7. [Naples, FL: Global Success
Corporation.] Reprinted in The Medicolegal
OB/GYN Newsletter 4, No. 4 (1996).
2. D. Daniel, “Ms Lovelace, Sen. Packwood, and
Dr. Hill,” The Medicolegal OB/GYN Newsletter 4,
No. 1 (1996): 1-5.
3. “Are Chaperones Needed in Anesthesia?”
Anesthesia Malpractice Prevention Special Report
(Naples, FL: Global Success Corporation, May
1996). Reprinted in The Medicolegal OB/GYN
Newsletter 4, No. 4 (1996).
4. “Chaperones Not Used Regularly; Risk Said
High,” OB-GYN Malpractice Prevention 3, No. 9
(1996): 65-67. [Naples, FL: Global Success
Corporation.] Reprinted in The Medicolegal
OB/GYN Newsletter 4, No. 4 (1996).
5. R.E. Anderson, “Report of Sexual Misconduct
Claims Review Panel” (San Diego: The Doctors’
Company, November 1996). Reprinted in The
Medicolegal OB/GYN Newsletter 6, No. 4 (1998):
36-40.
6. R.E. Anderson, “Letter to the Editor,” The
Medicolegal OB/GYN Newsletter 7, No. 1 (1999): 8.
7. E.M. Levine, “Letter to the Editor,” The
Medicolegal OB/GYN Newsletter 7, No. 1 (1999): 6-7.
8. J. Feeley, “Drafting an Airtight Sexual
Harassment Policy,” Physician’s Practice Digest
(March/April 1999): 26-27.
9. W.H. Hindle, “Letter to the Editor,” The
Medicolegal OB/GYN Newsletter 7, No. 3 (1999): 7-9.
10. American College of Obstetricians and
Gynecologists, Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations:
ACOG Committee Opinion No. 144 (Washington,
1994): 2.
11. American College of Obstetricians and
Gynecologists, Guidelines for Women’s Health Care
(Washington, 1995): 22, 86, 87, 142.
12. American College of Obstetricians and
Gynecologists, Sexual Dysfunction: ACOG
Educational Bulletin No. 211 (Washington, 1995): 6.
13. American College of Obstetricians and
Gynecologists, Sexual Assault: ACOG Bulletin No.
242 (Washington, 1997): 3.
14. “Chaperones May Keep Ob-Gyns Out of the
Courtroom,” ACOG Today 43, No. 7 (1999): 12.
15. S.J. Stagno et al, “Medical and Osteopathic
Boards’ Positions on Chaperones During
Gynecologic Examinations,” Obstet Gynecol 94
(1999): 352-354. u
NORTH
CAROLINA
MEDICAL BOARD
SEEKS MEDICAL
COORDINATOR
The North Carolina
Medical Board is recruiting
to fill a vacancy in the staff
position of Medical
Coordinator. The physi-cian
filling this position
will review, evaluate, and
make recommendations to
the Board about reports
concerning the conduct
and/or performance of
physicians licensed to prac-tice
medicine in North
Carolina.
Any physician interested
in being considered for the
full time position of
Medical Coordinator must
hold a full and unrestricted
North Carolina medical
license and should submit a
curriculum vitae to:
Mr Andrew Watry,
Executive Director
North Carolina
Medical Board
PO Box 20007
Raleigh, NC 27619
or
info@ncmedboard.org.
All inquiries regarding
this position should be
made in writing and be
directed to Mr Watry at
either of the addresses
above. Application dead-line
is March 15, 2000.
No. 4 1999 5
What Are the Position Statements of the NCMB
and to Whom Do They Apply?
The North Carolina Medical Board’s Position Statements are interpretive statements that
attempt to define or explain the meaning of laws or rules that govern the practice of physicians,*
physician assistants, and nurse practitioners in North Carolina, usually those relating to discipline.
They also set forth criteria or guidelines used by the Board’s staff in investigations and in the pros-ecution
or settlement of cases.
When considering the Board’s Position Statements, the following four points should be kept in
mind.
1. In its Position Statements, the Board attempts to articulate some of the standards it believes
applicable to the medical profession and to the other health care professions it regulates.
However, a Position Statement should not be seen as the promulgation of a new standard as of
the date of issuance or amendment. Some Position Statements are reminders of traditional, even
millennia old, professional standards, or show how the Board might apply such standards today.
2. The Position Statements are not intended to be comprehensive or to set out exhaustively
every standard that might apply in every circumstance. Therefore, the absence of a Position
Statement or a Position Statement’s silence on certain matters should not be construed as the
lack of an enforceable standard.
3. The existence of a Position Statement should not necessarily be taken as an indication of the
Board’s enforcement priorities.
4. A lack of disciplinary actions to enforce a particular standard mentioned in a Position
Statement should not be taken as an abandonment of the principles set forth therein.
The Board will continue to decide each case before it on all the facts and circumstances presented
in the hearing, whether or not the issues have been the subject of a Position Statement. The Board
intends that the Position Statements will reflect its philosophy on certain subjects and give licensees
some guidance for avoiding Board scrutiny. The principles of professionalism and performance
expressed in the Position Statements apply to all persons licensed and/or approved by the Board to
render medical care at any level.
*The words “physician” and “doctor” as used in the Position Statements refer to persons who are
MDs or DOs licensed by the Board to practice medicine and surgery in North Carolina.
[Adopted by the NCMB in 11/1999.] u
Two New Position Statements Adopted by NCMB:
Relate to Internet Prescribing and Closing of Practice
The North Carolina Medical Board recently
adopted two new position statements, one
related to the importance of a physician’s hav-ing
personal contact with a patient prior to pre-scribing
and the other dealing with closing or
leaving a medical practice. The first, adopted
in November 1999, is of particular interest in
relation to Internet prescribing. The second,
adopted in January 2000, is focused on the
problems faced when practices undergo
changes that could affect the continuity of
patient care.
CONTACT WITH PATIENTS
BEFORE PRESCRIBING
It is the position of the North Carolina
Medical Board that prescribing drugs to an
individual the prescriber has not personally
examined is usually inappropriate. Before pre-scribing
a drug, a physician should make an
informed medical judgment based on the cir-cumstances
of the situation and on his or her
training and experience. Ordinarily, this will
require that the physician personally perform
an appropriate history and physical examina-tion,
make a diagnosis, and formulate a thera-peutic
plan, a part of which might be a pre-scription.
This process must be documented
appropriately.
Prescribing for a patient whom the physician
has not personally examined may be suitable
under certain circumstances. These may
include admission orders for a newly hospital-ized
patient, prescribing for a patient of anoth-er
physician for whom the prescriber is taking
call, or continuing medication on a short-term
basis for a new patient prior to the patient’s
first appointment. Established patients may
not require a new history and physical exami-nation
for each new prescription, depending on
good medical practice.
It is the position of the Board that prescrib-ing
drugs to individuals the physician has never
met based solely on answers to a set of ques-tions,
as is common in Internet or toll-free tele-phone
prescribing, is inappropriate and unpro-fessional.
(Adopted 11/1999)
DEPARTURES FROM OR CLOS-INGS
OF MEDICAL PRACTICES
Departures from (when one or more physi-cians
leave and others remain) or closings of
medical practices are trying times. They can be
busy, emotional, and stressful for all concerned:
practitioners, staff, patients, and other parties
that may be involved. If mishandled, they can
significantly disrupt continuity of care. It is the
position of the North Carlina Medical Board
that during such times practitioners and other
parties that may be involved in such processes
must consider how their actions affect patients.
In particular, practitioners and other parties
that may be involved have the following oblig-ations.
Permit Patient Choice
It is the patient’s decision from whom to
receive care. Therefore, it is the responsibility
of all practitioners and other parties that may
be involved to ensure that:
l patients are notified of changes in the
practice, which is often done by newspa-per
advertisement and by letters to
patients currently under care;
l patients are told how to access their med-ical
records;
l patients are told how to reach any practi-tioner(
s) remaining in practice; and
l patients clearly understand that the choice
of a health care provider is the patients’.
Provide Continuity of Care
Practitioners continue to have obligations
toward patients during and after the depar-ture
from or closing of a medical practice.
Except in case of the death or other incapac-ity
of the practitioner, practitioners may not
abandon a patient or abruptly withdraw
from the care of a patient. Therefore,
patients should be given reasonable advance
notice to allow their securing other care.
Good continuity of care includes preserving,
keeping confidential, and providing appro-priate
access to medical records.* Also,
good continuity of care may often include
making appropriate referrals. The practi-tioner(
s) and other parties that may be
involved should ensure the requirements for
continuity of care are effectively addressed.
No practitioner, group of practitioners, or
other parties that may be involved should inter-fere
with the fulfillment of these obligations,
nor should practitioners put themselves in a
position where they cannot be assured these
obligations can be met.
*The Board’s position statement on the Retention
of Medical Records applies, even when practices
close permanently due to the retirement or death
of the practitioner.
(Adopted 1/2000) u
6 NCMB Forum
In October 1999, the North Carolina
Medical Board adopted the Position
Statement on End-of-Life Responsibilities
and Palliative Care that appears below. In
the same month, it joined with the North
Carolina Board of Pharmacy and the North
Carolina Board of Nursing in issuing a com-bined
statement on the same subject.
The NCMB adopted a statement on the
management of chronic non-malignant pain
in September 1996, following its sponsor-ship
of a special seminar on effective pain
control earlier that year. Along with the
Pharmacy and Nursing Boards, it also spon-sored
a special progam on end-of-life respon-sibilites
in October 1998. Adoption of the
two statements below reflects the NCMB’s
continuing commitment to actively address-ing
these issues.
END-OF-LIFE RESPONSIBILI-TIES
AND PALLIATIVE CARE
Assuring Patients
Death is part of life. When appropriate
processes have determined that the use of
life-sustaining or invasive interventions will
only prolong the dying process, it is incum-bent
on physicians to accept death “not as a
failure, but the natural culmination of our
lives.”*
It is the position of the North Carolina
Medical Board that patients and their fami-lies
should be assured of competent, com-prehensive
palliative care at the end of their
lives. Physicians should be knowledgeable
regarding effective and compassionate pain
relief, and patients and their families should
be assured such relief will be provided.
Palliative Care
There is no one definition of palliative
care, but the Board accepts that found in the
Oxford Textbook of Palliative Medicine: “The
study and management of patients with
active, progressive, far advanced disease for
whom the prognosis is limited and the focus
of care is the quality of life.” This is not
intended to exclude remissions and requires
that the management of patients be compre-hensive,
embracing the efforts of medical
clinicians and of those who provide psy-chosocial
services, spiritual support, and
hospice care.
A physician who provides palliative care,
encompassing the full range of comfort care,
NCMB Adopts Position Statement on End-of-Life Responsibilties
and Palliative Care, Joins Pharmacy and Nursing Boards
in Combined Statement
should assess his or her patient’s physical,
psychological, and spiritual conditions.
Because of the overwhelming concern of
patients about pain relief, special attention
should be given the effective assessment of
pain. It is particularly important that the
physician frankly but sensitively discuss with
the patient and the family their concerns and
choices at the end of life. As part of this dis-cussion,
the physician should make clear
that, in some cases, there are inherent risks
associated with effective pain relief in such
situations.
Opioid Use
The Board will assume opioid use in such
patients is appropriate if the responsible
physician is familiar with and abides by
acceptable medical guidelines regarding such
use, is knowledgeable about effective and
compassionate pain relief, and maintains an
appropriate medical record that details a
pain management plan. (See the Board’s
position statement on the Management of
Chronic Non-Malignant Pain for an outline
of what the Board expects of physicians in
the management of pain.) Because the
Board is aware of the inherent risks associat-ed
with effective pain relief in such situa-tions,
it will not interpret their occurrence as
subject to discipline by the Board.
Selected Guides
To assist physicians in meeting these responsi-bilities,
the Board recommends: Cancer Pain
Relief: With a Guide to Opioid Availability, 2nd ed
(1996), Cancer Pain Relief and Palliative Care
(1990), Cancer Pain Relief and Palliative Care in
Children (1999), and Symptom Relief in Terminal
Illness (1998), (World Health Organization,
Geneva); Management of Cancer Pain (1994),
(Agency for Health Care Policy and Research,
Rockville, MD); Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain, 4th
Edition (1999)(American Pain Society, Glenview,
IL); Hospice Care: A Physician’s Guide (1998)
(Hospice for the Carolinas, Raleigh); and the
Oxford Textbook of Palliative Medicine (1993)
(Oxford Medical, Oxford).
(Adopted 10/1999)
*Steven A. Schroeder, MD, President, Robert
Wood Johnson Foundation.
JOINT STATEMENT ON PAIN
MANAGEMENT IN END-OF-LIFE
CARE
(Adopted by the North Carolina Medical,
Nursing, and Pharmacy Boards)
Through dialogue with members of the
healthcare community and consumers, a
number of perceived regulatory barriers to
adequate pain management in end-of-life
care have been expressed to the Boards of
Medicine, Nursing, and Pharmacy. The fol-lowing
statement attempts to address these
misperceptions by outlining practice expec-tations
for physicians and other health care
professionals authorized to prescribe med-ications,
as well as nurses and pharmacists
involved in this aspect of end-of-life care.
The statement is based on:
l the legal scope of practice for each of
these licensed health professionals;
l professional collaboration and commu-nication
among health professionals
providing palliative care; and
l a standard of care that assures on-going
pain assessment, a therapeutic plan for
pain management interventions; and
evidence of adequate symptom man-agement
for the dying patient.
It is the position of all three Boards that
patients and their families should be assured
of competent, comprehensive palliative care
at the end of their lives. Physicians, nurses,
and pharmacists should be knowledgeable
regarding effective and compassionate pain
relief, and patients and their families should
be assured such relief will be provided.
Because of the overwhelming concern of
patients about pain relief, the physician
needs to give special attention to the effec-tive
assessment of pain. It is particularly
important that the physician frankly but sen-sitively
discuss with the patient and the fam-ily
their concerns and choices at the end of
life. As part of this discussion, the physician
should make clear that, in some end of life
care situations, there are inherent risks asso-ciated
with effective pain relief. The Medical
Board will assume opioid use in such patients is
appropriate if the responsible physician is famil-iar
with and abides by acceptable medical guide-lines
regarding such use, is knowledgeable about
effective and compassionate pain relief, and
maintains an appropriate medical record that
details a pain management plan. Because the
continued on page 7
No. 4 1999 7
NCMB Amends Two
Position Statements
At its meeting in January 2000, the North
Carolina Medical Board amended two of its
position statements to further clarify their
meaning. In modifying the final segment of
its Position Statement on the Physician-
Patient Relationship (see below), the Board
makes clear that the decision to terminate
Board is aware of the inherent risks associat-ed
with effective pain relief in such situa-tions,
it will not interpret their occurrence as
subject to discipline by the Board.
With regard to pharmacy practice, North
Carolina has no quantity restrictions on dis-pensing
controlled substances including
those in Schedule II. This is significant
when utilizing the federal rule that allows
the partial filling of Schedule II prescriptions
for up to 60 days. In these situations it
would minimize expenses and unnecessary
waste of drugs if the prescriber would note
on the prescription that the patient is termi-nally
ill and specify the largest anticipated
quantity that could be needed for the next
two months. The pharmacist could then
dispense smaller quantities of the prescrip-tion
to meet the patient’s needs up to the
total quantity authorized. Government-approved
labeling for dosage level and fre-quency
can be useful as guidance for patient
care. Health professionals may, on occasion,
determine that higher levels are justified in
specific cases. However, these occasions
would be exceptions to general practice and
would need to be properly documented to
establish informed consent of the patient
and family.
Federal and state rules also allow the fax
transmittal of an original prescription for
Schedule II drugs for hospice patients. If
the prescriber notes the hospice status of the
patient on the faxed document, it serves as
the original. Pharmacy rules also allow the
emergency refilling of prescriptions in
Schedules III, IV, and V. While this does not
apply to Schedule II drugs, it can be useful
in situations where the patient is using drugs
such as Vicodin for pain or Xanax for anxi-ety.
The nurse is often the health professional
most involved in on-going pain assessment,
implementing the prescribed pain manage-ment
plan, evaluating the patient’s response
to such interventions, and adjusting medica-tion
levels based on patient status. In order
to achieve adequate pain management, the
prescription must provide dosage ranges and
frequency parameters within which the
nurse may adjust (titrate) medication in
order to achieve adequate pain control.
Consistent with the licensee’s scope of prac-tice,
the RN or LPN is accountable for
implementing the pain management plan
utilizing his/her knowledge base and docu-mented
assessment of the patient’s needs.
The nurse has the authority to adjust medica-tion
levels within the dosage and frequency
ranges stipulated by the prescriber and accord-ing
to the agency’s established protocols.
However, the nurse does not have the
authority to change the medical pain man-agement
plan. When adequate pain man-agement
is not achieved under the currently
prescribed treatment plan, the nurse is
responsible for reporting such findings to
the prescriber and documenting this com-munication.
Only the physician or other
health professional with authority to pre-scribe
may change the medical pain manage-ment
plan.
Communication and collaboration
between members of the healthcare team,
and the patient and family are essential in
achieving adequate pain management in
end-of-life care. Within this interdisciplinary
framework for end of life care, effective pain
management should include:
l thorough documentation of all aspects
of the patient’s assessment and care;
l a working diagnosis and therapeutic
treatment plan including pharmacolog-ic
and non-pharmacologic interven-tions;
l regular and documented evaluation of
response to the interventions and, as
appropriate, revisions to the treatment
plan;
l evidence of communication among care
providers;
l education of the patient and family; and
l a clear understanding by the patient,
the family and healthcare team of the
treatment goals.
It is important to remind health profes-sionals
that licensing boards hold each
licensee accountable for providing safe,
effective care. Exercising this standard of
care requires the application of knowledge,
skills, as well as ethical principles focused on
optimum patient care while taking all appro-priate
measures to relieve suffering. The
healthcare team should give primary impor-tance
to the expressed desires of the patient
tempered by the judgement and legal
responsibilities of each licensed health pro-fessional
as to what is in the patient’s best
interest.
(Adopted 10/1999) u
NCMB Adopts Statements
continued from page 6
continued on page 8
the relationship with a patient must be made
by the physician personally, with written
notice given by the physician. In the
Position Statement on Laser Surgery (print-ed
in full below), an expansion of the first
paragraph makes clear that certain licensed
practitioners may perform laser surgery
under physician supervision.
TERMINATION OF THE PHYSI-CIAN-
PATIENT RELATIONSHIP
(Final Segment of the Position Statement on the
Physician-Patient Relationship)
The Board recognizes the physician’s right
to choose patients and to terminate the pro-fessional
relationship with them when he or
she believes it is best to do so. That being
understood, the Board maintains that termi-nation
of the physician-patient relationship
must be done in compliance with the physi-cian’s
obligation to support continuity of
care for the patient. The decision to termi-nate
the relationship must be made by the
physician personally. Further, termination
must be accomplished by appropriate writ-ten
notice given by the physician to the
patient, the relatives, or the legally responsi-ble
parties sufficiently far in advance (at least
30 days) to allow other medical care to be
secured. Should the physician be a member
of a group, the notice of termination must
state clearly whether the termination
involves only the individual physician or
includes other members of the group. In the
latter case, those members of the group join-ing
in the termination must be designated.
(Adopted 7/1995)
(Amended 7/1998, 1/2000)
LASER SURGERY
It is the position of the North Carolina
Medical Board that the revision, destruction,
incision, or other structural alteration of
human tissue using laser technology is
surgery.* Laser surgery should be per-formed
only by a physician or by a licensed
practitioner with appropriate medical train-ing
functioning under the supervision,
preferably on-site, of a physician or by those
categories of practitioners currently licensed
by this state to perform surgical services.
Licensees should use only devices
approved by the U.S. Food and Drug
Administration unless functioning under
protocols approved by institutional review
boards. As with all new procedures, it is the
licensee’s responsibility to obtain adequate
training and to make documentation of this
training available to the North Carolina
Medical Board on request.
Lasers are employed in certain hair-
8 NCMB Forum
NCMB Amends Statements
continued from page 7
removal procedures, as are various devices
that (1) manipulate and/or pulse light caus-ing
it to penetrate human tissue and (2) are
classified as “prescription” by the U.S. Food
and Drug Administration. Hair-removal
procedures using such technologies should
be performed only by a physician or by a
licensed practitioner with appropriate med-ical
training functioning under the supervi-sion,
preferably on-site, of a physician who
bears responsibility for those procedures.
*Definition of surgery as adopted by
the NCMB, November 1998:
Surgery, which involves the revision,
destruction, incision, or structural alteration
of human tissue performed using a variety of
methods and instruments, is a discipline that
includes the operative and non-operative
care of individuals in need of such interven-tion,
and demands pre-operative assessment,
judgment, technical skills, post-operative
management, and follow up.
(Adopted 7/1999)
(Amended 1/2000) u
SPECIAL NOTICE
OF HEARING AND
COMMENT
PERIOD ON PRO-POSED
AMEND-MENT
TO RULES:
NCMB Continuing
Medical Education
Requirements
Notice is hereby given in accordance with
G.S. 150B-21.2 that the NC Medical Board
intends to amend rule(s) cited as 21 NCAC
32R.0101-.0104.
Notice of Rule-making Proceedings was
published in the Register on August 2,
1999.
Proposed Effective Date: January 1, 2001
A Public Hearing will be conducted at
3:00 p.m. on March 3, 2000, at the NC
Medical Board, 1201 Front Street, Suite
100, Raleigh, NC 27609.
Comment Procedures: Written comments
will be accepted until close of business
March 16, 2000. Any interested person may
submit written comments on the proposed
rules by mailing the comments to Helen
Diane Meehleim, PO Box 20007, Raleigh,
NC 27619.
PROPOSAL
TITLE 21 CHAPTER 32 NORTH
CAROLINA MEDICAL BOARD
SUBCHAPTER 32R - CONTINU-ING
MEDICAL EDUCATION
(CME) REQUIREMENTS
.0101 CONTINUING MEDICAL EDU-CATION
(CME) REQUIRED
(a) CME is defined as knowledge and
skills generally recognized and accepted by
the profession as within the basic medical
sciences, the discipline of clinical medicine,
and the provision of healthcare to the public.
CME should maintain, develop, or improve
the physician’s knowledge, skills, profession-al
performance and relationships which
physicians use to provide services for their
patients, their practice, the public, or the
profession.
(b) Each person licensed to practice med-icine
in the State of North Carolina shall
complete no less than 150 hours of practice
relevant CME every three years in order to
enhance current medical competence, per-formance
or patient care outcome. At least
60 hours shall be in the educational
provider-initiated category as defined in
Rule .0102 of this Subchapter. The remain-ing
hours, if any, shall be in the physician-initiated
category as defined in Rule .0102
of this Subchapter. General medical reading
is not applicable to physician-initiated CME.
(c) The three year period described in
paragraph (b) above shall run from the
physician’s birthday beginning in the year
2001 or the first birthday following initial
licensure.
.0102 APPROVED CATEGORIES OF
CME
The following are the approved categories
of CME
(1) Physician-Initiated CME:
(a) Practice based self-study
(b) Colleague Consultations
(c) Office based outcomes research
(d) Study initiated by
patient inquiries
(e) Study of community
health problems
(f) Successful Specialty Board
Exam for certification or
recertification
(g) Teaching (professional,
patient/public health)
(h) Mentoring
(i) Morbidity and Mortality
(M&M) conference
(j) Journal clubs
(k) Creation of generic patient care
pathways and guidelines
(l) Competency Assessment
(2) Educational Provider-Initiated
CME: All education offered by
institutions or organizations accred-ited
by the Accreditation Council
on Continuing Medical Education
(ACCME) and reciprocating orga-nizations
or American Osteopathic
Association (AOA))
(a) Formal courses
(b) Scientific/clinical presentations,
or publications;
(c) Enduring Material
(Audio-Video);
(d) Skill development.
.0103 EXCEPTIONS
A licensee currently enrolled in an AOA or
Graduate Medical Education (ACGME)
accredited graduate medical education pro-gram
is exempt from the requirements of
Rule .0101 of this Section.
.0104 REPORTING
At the time of annual registration imme-diately
following the CME reporting period,
each Licensee shall report on the Board’s
annual registration form the number of
hours of practice-relevant CME obtained in
compliance with section .0101 of this
Subchapter. Records documenting CME
hours must be documented by categories for
six consecutive years and may be inspected
by the Board or its agents. u
NORTH CAROLINA
MEDICAL BOARD
SEEKS MEDICAL
COORDINATOR
The North Carolina Medical Board is
recruiting to fill a vacancy in the staff posi-tion
of Medical Coordinator. The physician
filling this position will review, evaluate, and
make recommendations to the Board about
reports concerning the conduct and/or per-formance
of physicians licensed to practice
medicine in North Carolina.
Any physician interested in being consid-ered
for the full time position of Medical
Coordinator must hold a full and unrestrict-ed
North Carolina medical license and
should submit a curriculum vitae to:
Mr Andrew Watry,
Executive Director, NC Medical Board
PO Box 20007
Raleigh, NC 27619
or
info@ncmedboard.org.
All inquiries regarding this position
should be made in writing and be directed to
Mr Watry at either of the addresses above.
Application deadline is March 15, 2000.
No. 4 1999 9
becoming more self-contained (less in need
of outside help) in doing so. Ameringer
describes this as a “change [in] focus from
guarding the gates to minding the store.”
Boards also have become more consumer-information
oriented, if only slightly.
Ameringer posits that medical boards
have been apart from rather than a part of
professional self-regulation of physicians.
The state and local medical societies had, in
the past, regulated the profession, if only
loosely, with the boards standing watch to
ensure the societies’ ability to do so. Part of
the reason this was so stems from differences
between the model of decision-making
employed by medical professionals and that
used by government agencies. Physicians
prefer “collegiality, informality, and confi-dentiality,”
leaving them with “independent
judgment and freedom from outside con-trol.”
Boards, obtaining their power from
governments, use a bureaucratic model,
“stressing hierarchy, formality, and account-ability.”
“Physicians [,therefore,] feared gov-ernmental
control of the disciplinary
process,” and, rather than embracing med-ical
board involvement in the disciplinary
process as professional self-regulation,
fought it. As a result, boards, rather than
being the profession’s chief (or, at least, last)
line of self-regulation, are a compromise
between self-regulation and government,
“temper[ing] bureaucracy with professional-ism,
discipline with rehabilitation, and dis-closure
with confidentiality.” Ameringer
concludes by cautioning that medical boards
are at risk of losing their relevance to private
enterprises providing medical care.
Though the author obviously draws heav-ily
on his experience with and direct obser-vation
of the Maryland board while he was
an assistant attorney general, the book is far
broader in scope, spanning two centuries of
history and the entire nation. It is well and
thoroughly researched, providing great force
to Ameringer’s arguments and valuable
guidance to readers who would explore the
subject in more depth. Those who want to
understand the forces that shaped and are
shaping state medical boards, and those who
want to consider what the near future may
bring, must read this book. u
Books about state medical boards are few.
[Of some note, though dated, are R.H.
Shryock, Medical Licensing in America:
1650-1965, The Johns Hopkins University
Press, 1967; R.C. Derbyshire, Medical
Licensure and Discipline in the United States,
The Johns Hopkins University Press, 1969;
W.O. Morris, Revocation of Professional
Licenses by Governmental Agencies, The
Michie Company, 1984.] When one comes
along, those interested in the subject matter
have high hopes. State Medical Boards and
the Politics of Public Protection, by Carl F.
Ameringer does not disappoint. Clearly
written, well presented, extensively annotat-ed,
and reasonably indexed, this book traces
the political forces that have shaped medical
boards in the United States from their incep-tion
to the present.
Ameringer begins by noting that the med-ical
profession secured the establishment of
medical boards principally to “protect the
public and the integrity of the medical pro-fession”
by defending the profession’s bor-ders
against pretenders or irregulars. For
most of their existence, medical boards have
focused outwardly, emphasizing licensing
over discipline, controlling entry to the pro-fession,
but doing little, if anything, to
police those already admitted. This latter
function was left to the local medical com-munities,
which often did little and, even at
their most vigorous, acted only informally
by boycott or the like.
—————————————————-
State Medical Boards and the Politics of Public
Protection
Carl F. Ameringer
The Johns Hopkins University Press,
Baltimore & London, 1999
176 pages (notes and index), $39.95 cloth
(ISBN 0-8018-5987-5)
—————————————————
Pressures mounted, including malpractice
litigation, organized public criticism, and
increasing concern over costs. Medical
boards, sometimes only begrudgingly, and
only in the last couple of decades, became
more active. They began involving them-selves
more in disciplining licensees and
Identification Badges
Required as of
October 1, 1999
During its 1999 session, the General
Assembly amended Chapter 90 of the
General Statutes by adding a new article,
Article 37, to require health care provider
identification. The new article is presented
below. It became effective on October 1,
1999.
ARTICLE 37
Health Care Practitioner Identification
§90-640. Identification badges
required.
(a) For purposes of this section, “health
care practitioner” means an individ-ual
who is licensed, certified, or regis-tered
to engage in the practice of
medicine, nursing, dentistry, pharma-cy,
or any related occupation involv-ing
the direct provision of health care
to patients.
(b)When providing health care to a
patient, a health care practitioner
shall wear a badge or other form of
identification displaying in readily
visible type the individual’s name and
the license, certification, or registra-tion
held by the practitioner. If the
identity of the individual’s license,
certification, or registration is com-monly
expressed by an abbreviation
rather than by full title, that abbrevi-ation
may be used on the badge or
other identification.
(c) The badge or other form of identifi-cation
is not required to be worn if
the patient is being seen in the health
care practitioner’s office and the
name and license of the practitioner
can be readily determined by the
patient from a posted license, a sign
in the office, a brochure provided to
patients, or otherwise.
(d) Each licensing board or other regula-tory
authority for health care practi-tioners
may adopt rules for exemp-tions
from wearing a badge or other
form of identification, or for allowing
use of the practitioner’s first name
only, when necessary for the health
care practitioner’s safety or for thera-peutic
concerns.
(e) Violation of this section is a ground
for disciplinary action against the
health care practitioner by the practi-tioner’s
licensing board or other reg-ulatory
authority. u
REVIEW
State Medical Boards and the Politics of Public
Protection
James A. Wilson, JD
Director, NCMB Legal Department
10 NCMB Forum
Preamble
The principles of professionalism and performance expressed in the posi-tion
statements of the North Carolina Medical Board apply to all persons
licensed and/or approved by the Board to render medical care at any level.
The words “physician” and “doctor” as used in the position statements of
the North Carolina Medical Board refer to persons who are MDs or DOs
licensed by the Board to practice medicine and surgery in North Carolina.
WHAT ARE THE POSITION STATEMENTS OF THE BOARD
AND TO WHOM DO THEY APPLY?
The North Carolina Medical Board’s Position Statements are interpretive
statements that attempt to define or explain the meaning of laws or rules
that govern the practice of physicians,* physician assistants, and nurse prac-titioners
in North Carolina, usually those relating to discipline. They also
set forth criteria or guidelines used by the Board’s staff in investigations and
in the prosecution or settlement of cases.
When considering the Board’s Position Statements, the following four
points should be kept in mind.
1. In its Position Statements, the Board attempts to articulate some of
the standards it believes applicable to the medical profession and to the
other health care professions it regulates. However, a Position
Statement should not be seen as the promulgation of a new standard
as of the date of issuance or amendment. Some Position Statements
are reminders of traditional, even millennia old, professional stan-dards,
or show how the Board might apply such standards today.
2. The Position Statements are not intended to be comprehensive or to
set out exhaustively every standard that might apply in every circum-stance.
Therefore, the absence of a Position Statement or a Position
Statement’s silence on certain matters should not be construed as the
lack of an enforceable standard.
3. The existence of a Position Statement should not necessarily be taken
as an indication of the Board’s enforcement priorities.
4. A lack of disciplinary actions to enforce a particular standard men-tioned
in a Position Statement should not be taken as an abandonment
of the principles set forth therein.
The Board will continue to decide each case before it on all the facts and
circumstances presented in the hearing, whether or not the issues have been
the subject of a Position Statement. The Board intends that the Position
Statements will reflect its philosophy on certain subjects and give licensees
some guidance for avoiding Board scrutiny. The principles of professional-ism
and performance expressed in the Position Statements apply to all per-sons
licensed and/or approved by the Board to render medical care at any
level.
*The words “physician” and “doctor” as used in the Position Statements
refer to persons who are MDs or DOs licensed by the Board to practice
medicine and surgery in North Carolina.
(Adopted 11/1999)
THE PHYSICIAN-PATIENT RELATIONSHIP
The North Carolina Medical Board recognizes the movement toward
restructuring the delivery of health care and the significant needs that moti-vate
that movement. The resulting changes are providing a wider range and
variety of health care delivery options to the public. Notwithstanding these
developments in health care delivery, the duty of the physician remains the
same: to provide competent, compassionate, and economically prudent care
to all his or her patients. Whatever the health care setting, the Board holds
that the physician’s fundamental relationship is always with the patient, just
as the Board’s relationship is always with the individual physician. Having
assumed care of a patient, the physician may not neglect that patient nor fail
for any reason to prescribe the full care that patient requires in accord with
the standards of acceptable medical practice. Further, it is the Board’s posi-tion
that it is unethical for a physician to allow financial incentives or con-tractual
ties of any kind to adversely affect his or her medical judgment or
patient care. Therefore, it is the position of the North Carolina Medical
Board that any act by a physician that violates or may violate the trust a
patient places in the physician places the relationship between physician and
patient at risk. This is true whether such an act is entirely self-determined
or the result of the physician’s contractual association with a health care
entity. The Board believes the interests and health of the people of North
Carolina are best served when the physician-patient relationship remains
inviolate. The physician who puts the physician-patient relationship at risk
also puts his or her relationship with the Board in jeopardy.
Elements of the Physician-Patient Relationship
The North Carolina Medical Board licenses physicians as a part of regu-lating
the practice of medicine in this state. Receiving a license to practice
medicine grants the physician privileges and imposes great responsibilities.
The people of North Carolina expect a licensed physician to be competent
and worthy of their trust. As patients, they come to the physician in a vul-nerable
condition, believing the physician has knowledge and skill that will
be used for their benefit.
Patient trust is fundamental to the relationship thus established. It
requires that
n there be adequate communication between the physician and the
patient;
n there be no conflict of interest between the patient and the physician
or third parties;
n intimate details of the patient’s life shared with the physician be held
in confidence;
n the physician maintain professional knowledge and skills;
n there be respect for the patient’s autonomy;
n the physician be compassionate;
Table of Contents
What are the Position Statements of the Board and
to Whom Do They Apply? .......................................................10
The Physician-Patient Relationship ..................................................10
Documentation of the Physician-Patient Relationship......................11
Medical Record Documentation ......................................................11
Access to Physician Records.............................................................11
Retention of Medical Records..........................................................12
Departures from or Closings of Medical Practices............................12
The Retired Physician......................................................................12
Advance Directives and Patient Autonomy ......................................13
Availability of Physicians After Hours..............................................13
Guidelines for Avoiding Misunderstandings During
Physical Examinations...............................................................13
Sexual Exploitation of Patients.........................................................13
Contact With Patients Before Prescribing.........................................14
Writing of Prescriptions ...................................................................14
Treatment of and Prescribing for Family Members...........................14
The Use of Anorectics in Treatment of Obesity ...............................14
Prescribing Legend or Controlled Substances for Other Than
Valid Medical or Therapeutic Purposes, with Particular
Reference to Substances or Preparations with
Anabolic Properties ...................................................................14
Management of Chronic Non-Malignant Pain .................................14
End-of-Life Responsibilities and Palliative Care ...............................15
(Medical, Nursing, Pharmacy Boards: Joint Statement on
Pain Management in End-of-Life Care).....................................15
Laser Surgery ..................................................................................16
Ophthalmologists: Care of Cataract Patients....................................16
HIV/HBV Infected Health Care Workers........................................17
Professional Obligation to Report Incompetence,
Impairment, and Unethical Conduct.........................................17
Continuing Medical Education ........................................................17
Fee Splitting ....................................................................................17
Unethical Agreements in Complaint Settlements .............................17
Position Statements of the North Carolina Medical Board
No. 4 1999 11
n the physician be an advocate for needed medical care, even at the expense
of the physician’s personal interests; and
n the physician provide neither more nor less than the medical problem
requires.
The Board believes the interests and health of the people of North Carolina
are best served when the physician-patient relationship, founded on patient
trust, is considered sacred, and when the elements crucial to that relationship
and to that trust — communication, patient primacy, confidentiality, compe-tence,
patient autonomy, compassion, selflessness, and appropriate care — are
foremost in the hearts, minds, and actions of the physicians licensed by the
Board.
This same fundamental physician-patient relationship also applies to mid-level
health care providers such as physician assistants and nurse practitioners
in all practice settings.
Termination of the Physician-Patient Relationship
The Board recognizes the physician’s right to choose patients and to termi-nate
the professional relationship with them when he or she believes it is best
to do so. That being understood, the Board maintains that termination of the
physician-patient relationship must be done in compliance with the physician’s
obligation to support continuity of care for the patient. The decision to ter-minate
the relationship must be made by the physician personally. Further, ter-mination
must be accomplished by appropriate written notice given by the
physician to the patient, the relatives, or the legally responsible parties suffi-ciently
far in advance (at least 30 days) to allow other medical care to be
secured. Should the physician be a member of a group, the notice of termi-nation
must state clearly whether the termination involves only the individual
physician or includes other members of the group. In the latter case, those
members of the group joining in the termination must be designated.
(Adopted 7/1995)
(Amended 7/1998, 1/2000)
DOCUMENTATION OF THE PHYSICIAN-PATIENT
RELATIONSHIP*
It is the position of the North Carolina Medical Board that when a physi-cian-
patient relationship is established, it should be documented by medical
records, which should contain, at a minimum, the following:
1. an appropriate history and physical and/or mental examination for the
patient’s chief complaint relevant to the physician’s specialty;
2. results of diagnostic tests (when indicated);
3. a working diagnosis;
4. notes on treatment(s) undertaken;
5. a record by date of all prescriptions for drugs, with names of medications,
strengths, dosages, quantity, and number of refills; and
6. a record of billings.
*See also position statement on Medical Record Documentation.
(Adopted 5/1991)
(Amended 5/1996)
MEDICAL RECORD DOCUMENTATION
p The North Carolina Medical Board takes the position that physicians and
physician extenders should maintain accurate patient care records of history,
physical findings, assessments of findings, and the plan for treatment. The
Board recommends the Problem Oriented Medical Record method known as
SOAP (developed by Lawrence Weed).
p SOAP charting is a schematic recording of facts and information. The S
refers to “subjective information” (patient history and testimony about feel-ings).
The O refers to objective material and measurable data (height, weight,
respiration rate, temperature, and all examination findings). The A is the
assessment of the subjective and objective material that can be the diagnosis
but is always the total impression formed by the care provided after review of
all materials gathered. And finally, the P is the treatment plan presented in suf-ficient
detail to allow another care provider to follow the plan to completion.
The plan should include a follow-up schedule.
p Such a chronological document
n records pertinent facts about an individual’s health and wellness;
n enables the treating care provider to plan and evaluate treatments or
interventions;
n enhances communication between professionals, assuring the patient
optimum continuity of care;
n assists both patient and physician to communicate to third party partici-pants;
n allows the physician to develop an ongoing quality assurance program;
n provides a legal document to verify the delivery of care; and
n is available as a source of clinical data for research and education.
p Certain items should appear in the medical record as a matter of course:
n the purpose of the patient encounter;
n the assessment of patient condition;
n the services delivered—in full detail;
n the rationale for the requirement of any support services;
n the results of therapies or treatments;
n the plan for continued care;
n whether or not informed consent was obtained; and, finally,
n that the delivered services were appropriate for the condition of the
patient.
p The record should be legible. When the care giver will not write legibly,
notes should be dictated, transcribed, reviewed, and signed within reasonable
time. Signature, date, and time should also be legible. All therapies should be
documented as to indications, method of delivery, and response of the patient.
Special instructions given to other care givers or the patient should be docu-mented:
Who received the instructions and did they appear to understand
them?
p All drug therapies should be named, with dosage instructions and indica-tion
of refill limits. All medications a patient receives from all sources should
be inventoried and listed to include the method by which the patient under-stands
they are to be taken. Any refill prescription by phone should be record-ed
in full detail.
p The physician needs and the patient deserves clear and complete documen-tation.
(Adopted 5/1994)
(Amended 5/1996)
ACCESS TO PHYSICIAN RECORDS
p A physician’s policies and practices relating to medical records should be
designed to benefit the health and welfare of patients, whether current or past,
and should facilitate the transfer of clear and reliable information about a
patient’s care when such a transfer is requested by the patient or anyone autho-rized
by law to act on the patient’s behalf.
It is the position of the North Carolina Medical Board that notes made by
a physician in the course of diagnosing and treating patients are primarily for
the physician’s use and are therefore the property of that physician. Moreover,
the resulting record is a confidential document and should only be released
with proper written consent of the patient. Each physician has a duty on the
request of a patient to release a copy or a summary of the record in a timely
manner to the patient or anyone the patient designates. If a summary is pro-vided,
it should include all the information and data necessary to allow conti-nuity
of care by another physician.
The physician may charge a reasonable fee for the preparation and/or the
photocopying of the materials. To assist in avoiding misunderstandings, and
for a reasonable fee, the physician should be willing to review the materials
with the patient at the patient’s request. Materials should not be held because
an account is overdue or a bill is owed.
Should it be the physician’s policy not to include in either the copied or the
summarized record those materials that were provided by other physicians
regarding the patient’s former or current care, he or she should advise the
patient of that fact and of ways those materials might be obtained.
12 NCMB Forum
p Should it be the physician’s policy to complete insurance or other forms for
established patients, it is the position of the Board that the physician should
complete those forms in a timely manner. If a form is simple, the physician
should perform this task for no fee. If a form is complex, the physician may
charge a reasonable fee.
p To prevent misunderstandings, the physician’s policies about providing
copies or summaries of patient records and about completing forms should be
made available in writing to patients when the physician-patient relationship
begins.
(Adopted 11/1993)
(Amended 5/1996)
(Amended 9/1997)
RETENTION OF MEDICAL RECORDS
n The North Carolina Medical Board supports and adopts the following lan-guage
of Section 7.05 of the American Medical Association’s current Code of
Medical Ethics regarding the retention of medical records by physicians.
7.05: Retention of Medical Records - Physicians have an obligation to retain
patient records which may reasonably be of value to a patient. The following
guidelines are offered to assist physicians in meeting their ethical and legal
obligations:
(1) Medical considerations are the primary basis for deciding how long to
retain medical records. For example, operative notes and chemothera-py
records should always be part of the patient’s chart. In deciding
whether to keep certain parts of the record, an appropriate criterion is
whether a physician would want the information if he or she were see-ing
the patient for the first time.
(2) If a particular record no longer needs to be kept for medical reasons, the
physician should check state laws to see if there is a requirement that
records be kept for a minimum length of time. Most states will not have
such a provision. If they do, it will be part of the statutory code or state
licensing board.
(3) In all cases, medical records should be kept for atleast as long as the
length of time of the statute of limitations for medical malpractice
claims. The statute of limitations may be three or more years, depend-ing
on the state law. State medical associations and insurance carriers
are the best resources for this information.
(4) Whatever the statute of limitations, a physician should measure time
from the last professional contact with the patient.
(5) If a patient is a minor, the statute of limitations for medical malpractice
claims may not apply until the patient reaches the age of majority.
(6) Immunization records always must be kept.
(7) The records of any patient covered by Medicare or Medicaid must be
kept at least five years.
(8) In order to preserve confidentiality when discarding old records, all doc-uments
should be destroyed.
(9) Before discarding old records, patients should be given an opportunity
to claim the records or have them sent to another physician, if it is fea-sible
to give them the opportunity.
............................
Please Note:
a. North Carolina has no statute relating specifically to the retention of med-ical
records.
b. Several North Carolina statutes relate to time limitations for the filing of
malpractice actions.
Legal advice should be sought regarding such limitations.
(Adopted 5/1998)
DEPARTURES FROM OR CLOSINGS OF MEDICAL PRACTICES
Departures from (when one or more physicians leave and others remain) or
closings of medical practices are trying times. They can be busy, emotional,
and stressful for all concerned: practitioners, staff, patients, and other parties
that may be involved. If mishandled, they can significantly disrupt continuity
of care. It is the position of the North Carlina Medical Board that during such
times practitioners and other parties that may be involved in such processes
must consider how their actions affect patients. In particular, practitioners and
other parties that may be involved have the following obligations.
p Permit Patient Choice
n It is the patient’s decision from whom to receive care. Therefore, it is the
responsibility of all practitioners and other parties that may be involved
to ensure that:
(1) patients are notified of changes in the practice, which is often done
by newspaper advertisement and by letters to patients currently
under care;
(2) patients are told how to access their medical records;
(3) patients are told how to reach any practitioner(s) remaining in prac-tice;
and
(4) patients clearly understand that the choice of a health care provider
is the patients’.
p Provide Continuity of Care
Practitioners continue to have obligations toward patients during and
after the departure from or closing of a medical practice. Except in case
of the death or other incapacity of the practitioner, practitioners may not
abandon a patient or abruptly withdraw from the care of a patient.
Therefore, patients should be given reasonable advance notice to allow
their securing other care. Good continuity of care includes preserving,
keeping confidential, and providing appropriate access to medical
records.* Also, good continuity of care may often include making appro-priate
referrals. The practitioner(s) and other parties that may be
involved should ensure the requirements for continuity of care are effec-tively
addressed.
No practitioner, group of practitioners, or other parties that may be
involved should interfere with the fulfillment of these obligations, nor should
practitioners put themselves in a position where they cannot be assured these
obligations can be met.
*The Board’s position statement on the Retention of Medical Records applies,
even when practices close permanently due to the retirement or death of the
practitioner.
(Adopted 1/2000)
THE RETIRED PHYSICIAN
n The retirement of a physician is defined by the North Carolina Medical
Board as the total and complete cessation of the practice of medicine and/or
surgery by the physician in any form or setting. According to the Board’s def-inition,
the retired physician is not required to maintain a currently registered
license and SHALL NOT:
l provide patient services;
l order tests or therapies;
l prescribe, dispense, or administer drugs;
l perform any other medical and/or surgical acts; or
l receive income from the provision of medical and/or surgical services
performed following retirement.
n The North Carolina Medical Board is aware that a number of physicians
consider themselves “retired,” but still hold a currently registered medical
license (full, volunteer, or limited) and provide professional medical and/or
surgical services to patients on a regular or occasional basis. Such physicians
customarily serve the needs of previous patients, friends, nursing home resi-dents,
free clinics, emergency rooms, community health programs, etc. The
Board commends those physicians for their willingness to continue service fol-lowing
“retirement,” but it recognizes such service is not the “complete cessa-tion
of the practice of medicine” and therefore must be joined with an undi-minished
awareness of professional responsibility. That responsibility means
that such physicians SHOULD:
l practice within their areas of professional competence;
l prepare and keep medical records in accord with good professional prac-tice;
and
No. 4 1999 13
l maintain their competence through an active continuing medical educa-tion
effort.
n The Board also reminds “retired” physicians with currently registered
licenses that all federal and state laws and rules relating to the practice of med-icine
and/or surgery apply to them, that the position statements of the Board
are as relevant to them as to physicians in full and regular practice, and that
they continue to be subject to the risks of liability for any medical and/or sur-gical
acts they perform.
(Adopted 1/1997)
ADVANCE DIRECTIVES AND PATIENT AUTONOMY
Advances in medical technology have given physicians the ability to prolong
the mechanics of life almost indefinitely. Because of this, physicians must be
aware that North Carolina law specifically recognizes the individual’s right to
a peaceful and natural death. NC Gen Stat 90-320 (a) (1993) reads:
The General Assembly recognizes as a matter of public policy that
an individual’s rights include the right to a peaceful and natural
death and that a patient or his representative has the fundamental
right to control the decisions relating to the rendering of his own
medical care, including the decision to have extraordinary means
withheld or withdrawn in instances of a terminal condition.
They must also be aware that North Carolina law empowers any adult indi-vidual
with understanding and capacity to make a Health Care Power of
Attorney [NC Gen Stat 32A-17 (1995)] and stipulates that, when a patient
lacks understanding or capacity to make or communicate health care decisions,
the instructions of a duly appointed health care agent are to be taken as those
of the patient unless evidence to the contrary is available [NC Gen Stat 32A-
24(b)(1995).
p It is the position of the North Carolina Medical Board that it is in the best
interest of the patient and of the physician/patient relationship to encourage
patients to complete documents that express their wishes for the kind of care
they desire at the end of their lives. Physicians should encourage their patients
to appoint a health care agent to act with the Health Care Power of Attorney
and to provide documentation of the appointment to the responsible physi-cian(
s). Further, physicians should provide full information to their patients
in order to enable those patients to make informed and intelligent decisions
prior to a terminal illness.
p It is also the position of the Board that physicians are ethically obligated to
follow the wishes of the terminally ill or incurable patient as expressed by and
properly documented in a declaration of a desire for a natural death.
p It is also the position of the Board that when the wishes of a patient are con-trary
to what a physician believes in good conscience to be appropriate care,
the physician may withdraw from the case once continuity of care is assured.
p It is also the position of the Board that withdrawal of life prolonging tech-nologies
is in no manner to be construed as permitting diminution of nursing
care, relief of pain, or any other care that may provide comfort for the patient.
(Adopted 7/1993)
(Amended 5/1996)
AVAILABILITY OF PHYSICIANS AFTER HOURS
p It is the position of the North Carolina Medical Board that once a physi-cian-
patient relationship is created, it is the duty of the physician to provide
care whenever it is needed or to assure that proper physician backup is avail-able
to take care of the patient during or outside normal office hours. If the
physician is not generally available outside normal office hours and does not
have an arrangement whereby another physician is available at such times, this
fact must be clearly communicated to the patient, verbally and in writing,
along with written instructions for securing care at such times.
p If the condition of the patient is such that the need for care at a time the
physician cannot be available is anticipated, the physician should consider
transfer of care to another physician who can be available when needed.
(Adopted 7/1993)
(Amended 5/1996)
GUIDELINES FOR AVOIDING MISUNDERSTANDINGS
DURING PHYSICAL EXAMINATIONS
It is the position of the North Carolina Medical Board that proper care and
sensitivity are needed during physical examinations to avoid misunderstand-ings
that could lead to charges of sexual misconduct against physicians. In
order to prevent such misunderstandings, the Board offers the following
guidelines.
1. Sensitivity to patient dignity should be considered by the physician when
undertaking a physical examination. The patient should be assured of
adequate auditory and visual privacy and should never be asked to dis-robe
in the presence of the physician. Examining rooms should be safe,
clean, and well maintained, and should be equipped with appropriate
furniture for examination and treatment. Gowns, sheets and/or other
appropriate apparel should be made available to protect patient dignity
and decrease embarrassment to the patient while a thorough and profes-sional
examination is conducted.
2. Whatever the sex of the patient, a third party should be readily available
at all times during a physical examination, and it is advisable that a third
party be present when the physician performs an examination of the
breast(s), genitalia, or rectum. When appropriate or when requested by
the patient, the physician should have a third party present throughout
the examination or at any given point during the examination.
3. The physician should individualize the approach to physical examina-tions
so that each patient’s apprehension, fear, and embarrassment are
diminished as much as possible. An explanation of the necessity of a
complete physical examination, the components of that examination,
and the purpose of disrobing may be necessary in order to minimize the
patient’s possible misunderstanding.
4. The physician and staff should exercise the same degree of professional-ism
and care when performing diagnostic procedures (eg, electro-car-diograms,
electromyograms, endoscopic procedures, and radiological
studies, etc), as well as during surgical procedures and postsurgical fol-low-
up examinations when the patient is in varying stages of conscious-ness.
5 The physician should be on the alert for suggestive or flirtatious behav-ior
or mannerisms on the part of the patient and should not permit a
compromising situation to develop.
(Adopted 5/1991)
(Amended 5/1993)
(Amended 5/1996)
SEXUAL EXPLOITATION OF PATIENTS
p It is the position of the North Carolina Medical Board that entering into a
sexual relationship with a patient, consensual or otherwise, is unprofessional
conduct and is grounds for the suspension or revocation of a physician’s
license. Such conduct is not tolerated.
p As with other disciplinary actions taken by the Board, Board action against
a medical licensee for sexual exploitation of a patient or patients is published
by the Board, the nature of the offense being clearly specified. It is also
released to the news media, to state and federal government, and to medical
and professional organizations.
p This position also applies to mid-level health care providers such as physi-cian
assistants, nurse practitioners, and EMTs authorized to perform medical
acts by the Board.
(Adopted 5/1991)
(Amended 4/1996)
14 NCMB Forum
CONTACT WITH PATIENTS BEFORE PRESCRIBING
p It is the position of the North Carolina Medical Board that prescribing
drugs to an individual the prescriber has not personally examined is usually
inappropriate. Before prescribing a drug, a physician should make an
informed medical judgment based on the circumstances of the situation and
on his or her training and experience. Ordinarily, this will require that the
physician personally perform an appropriate history and physical examination,
make a diagnosis, and formulate a therapeutic plan, a part of which might be
a prescription. This process must be documented appropriately.
p Prescribing for a patient whom the physician has not personally examined
may be suitable under certain circumstances. These may include admission
orders for a newly hospitalized patient, prescribing for a patient of another
physician for whom the prescriber is taking call, or continuing medication on
a short-term basis for a new patient prior to the patient’s first appointment.
Established patients may not require a new history and physical examination
for each new prescription, depending on good medical practice.
p It is the position of the Board that prescribing drugs to individuals the
physician has never met based solely on answers to a set of questions, as is
common in Internet or toll-free telephone prescribing, is inappropriate and
unprofessional.
[Adopted 11/1999]
WRITING OF PRESCRIPTIONS
p It is the position of the North Carolina Medical Board that prescriptions for
controlled substances or mind-altering chemicals should be written in ink or
indelible pencil or typewritten and should be manually signed by the practi-tioner
at the time of issuance. Quantities should be indicated in both numbers
AND words, eg, 30 (thirty). Such prescriptions must not be written on pre-signed
prescription blanks.
p Each prescription for a DEA controlled substance (2, 2N, 3, 3N, 4, and 5)
should be written on a separate prescription blank. Multiple medications may
appear on a single prescription blank only when none are DEA-controlled.
p No prescriptions, including those for controlled substances or mind-alter-ing
chemicals, should be issued for a patient in the absence of a documented
physician-patient relationship.
p No prescription for controlled substances or mind-altering chemicals should
be issued by a practitioner for his or her personal use.
p The practice of pre-signing prescriptions is unacceptable to the Board.
(Adopted 5/1991 and 9/1992)
(Amended 5/1996)
TREATMENT OF AND PRESCRIBING FOR FAMILY MEMBERS
p It is the position of the North Carolina Medical Board that, generally, a
physician should not prescribe for family members. Treating one’s family is
not illegal, but the Board wishes to remind physicians that such treatment and
prescribing practices may provide less than optimal care for a family member.
Written records of all therapies, including but not limited to writing prescrip-tions
for controlled substances and the medical indications for them, should be
maintained. The purpose of a medical record is to provide accurate informa-tion
regarding diagnosis and management of illness, but such record keeping
is too frequently neglected when a physician manages illness in his or her fam-ily.
The Board urges physicians to delegate the medical care of themselves and
their family members to one or more of their colleagues in order to preclude
involvement with governmental regulatory agencies that monitor physicians’
prescribing practices.
p Furthermore,
1. treatment of the immediate family members should be reserved for minor
illnesses, temporary or emergency situations;
2. appropriate consultations should be obtained for the management of
major or extended periods of illness;
3. any prescriptions issued should be within the scope of the physician’s
medical practice;
4. no Schedule 2, 3, or 4 controlled substances should be given or pre-scribed
for family members except in emergency situations;
5. appropriate records should be maintained for written prescriptions
and/or administration of any Schedule 2, 3, or 4 controlled substances.
(Adopted 5/1991)
(Amended 5/1996)
THE USE OF ANORECTICS IN TREATMENT OF OBESITY
p It is the position of the North Carolina Medical Board that under particu-lar
circumstances certain anorectic agents may have an adjunctive use in the
treatment of obesity. Good medical practice requires that such use be guided
by a written protocol that is based on published medical data and that patient
compliance and progress will be documented.
p It remains the policy of the Board that there is no place for the use of
amphetamines or methamphetamines in the treatment of obesity.
(Adopted 10/1987)
(Amended 3/1996)
PRESCRIBING LEGEND OR CONTROLLED SUBSTANCES FOR
OTHER THAN VALID MEDICAL OR THERAPEUTIC PURPOS-ES,
WITH PARTICULAR REFERENCE TO SUBSTANCES OR
PREPARATIONS WITH ANABOLIC PROPERTIES
General
p It is the position of the North Carolina Medical Board that prescribing any
controlled or legend substance for other than a valid medical or therapeutic
purpose is unprofessional conduct.
The physician shall complete and maintain a medical record that establish-es
the diagnosis, the basis for that diagnosis, the purpose and expected
response to therapeutic medications, and the plan for the use of medications
in treatment of the diagnosis.
The Board is not opposed to the use of innovative, creative therapeutics;
however, treatments not having a scientifically valid basis for use should be
studied under investigational protocols so as to assist in the establishment of
evidence-based, scientific validity for such treatments.
Substances/Preparations with Anabolic Properties
p The use of anabolic steroids, testosterone and its analogs, human growth
hormone, human chorionic gonadotrophin, other preparations with anabolic
properties, or autotransfusion in any form, to enhance athletic performance or
muscle development for cosmetic, nontherapeutic reasons, in the absence of an
established disease or deficiency state, is not a medically valid use of these med-ications.
The use of these medications under these conditions will subject the person
licensed by the Board to investigation and potential sanctions.
The Board recognizes that most anabolic steroid abuse occurs outside the
medical system. It wishes to emphasize the physician’s role as educator in pro-viding
information to individual patients and the community, and specifically
to high school and college athletes, as to the dangers inherent in the use of
these medications.
(Adopted 5/1998)
(Amended 7/1998)
MANAGEMENT OF CHRONIC NON-MALIGNANT PAIN
It has become increasingly apparent to physicians and their patients that the
use of effective pain management has not kept pace with other advances in
medical practice. There are several factors that have contributed to this. These
include a history of relatively low priority given pain management in our
health care system, the incomplete integration of current knowledge in med-ical
education and clinical practice, a sparsity of practitioners specifically
No. 4 1999 15
trained in pain management, and the fear of legal consequences when con-trolled
substances are used—fear shared by physician and patient. There are
three general categories of pain.
Acute Pain is associated with surgery, trauma and acute illness. It has
received its share of attention by physicians, its treatment by various
means is widely accepted by patients, and it has been addressed in guide-lines
issued by the Agency for Health Care Policy and Research of the
U.S. Department of Health and Human Services.
Cancer Pain has been receiving greater attention and more enlightened
treatment by physicians and patients, particularly since development of
the hospice movement. It has also been addressed in AHCPR guidelines.
Chronic Non-Malignant Pain is often difficult to diagnose, often
intractable, and often undertreated. It is the management of chronic
non-malignant pain on which the North Carolina Medical Board wishes
to focus attention in this position statement.
p The North Carolina Medical Board recognizes that many strategies exist for
treating chronic non-malignant pain. Because such pain may have many caus-es
and perpetuating factors, treatment will vary from behavioral and rehabili-tation
approaches to the use of a number of medications, including opioids.
Specialty groups in the field point out that most chronic non-malignant pain
is best managed in a coordinated way, using a number of strategies in concert.
Inadequate management of such pain is not uncommon, however, despite the
availability of safe and effective treatments.
The Board is aware that some physicians avoid prescribing controlled sub-stances
such as opioids in treating chronic non-malignant pain. While it does
not suggest those physicians abandon their reservations or professional judge-ment
about using opioids in such situations, neither does the Board wish to be
an obstacle to proper and effective management of chronic pain by physicians.
It should be understood that the Board recognizes opioids can be an appropriate treat-ment
for chronic pain.
p It is the position of the North Carolina Medical Board that effective man-agement
of chronic pain should include:
n thorough documentation of all aspects of the patient’s assessment and
care;
n a thorough history and physical examination, including a drug and pain
history;
n appropriate studies;
n a working diagnosis and treatment plan;
n a rationale for the treatment selected;
n education of the patient;
n clear understanding by the patient and physician of methods and goals of
treatment;
n a specific follow-up protocol, which must be adhered to;
n regular assessment of treatment efficacy;
n consultation with specialists in pain medicine, when warranted; and
n use of a multidisciplinary approach, when indicated.
p The Board expects physicians using controlled substances in the manage-ment
of chronic pain to be familiar with conditions such as:
n physical dependence;
n respiratory depression and other side effects;
n tolerance;
n addiction; and
n pseudo addiction.
There is an abundance of literature available on these topics and on the effec-tive
management of pain. The physician’s knowledge should be regularly
updated in these areas.
p No physician need fear reprisals from the Board for appropriately prescrib-ing,
as described above, even large amounts of controlled substances indefi-nitely
for chronic non-malignant pain.
p Nothing in this statement should be construed as advocating the imprudent
use of controlled substances.
(Adopted 9/1996)
END-OF-LIFE RESPONSIBILITIES AND PALLIATIVE CARE
Assuring Patients
p Death is part of life. When appropriate processes have determined that the
use of life-sustaining or invasive interventions will only prolong the dying
process, it is incumbent on physicians to accept death “not as a failure, but the
natural culmination of our lives.”* It is the position of the North Carolina
Medical Board that patients and their families should be assured of competent,
comprehensive palliative care at the end of their lives. Physicians should be
knowledgeable regarding effective and compassionate pain relief, and patients
and their families should be assured such relief will be provided.
Palliative Care
p There is no one definition of palliative care, but the Board accepts that
found in the Oxford Textbook of Palliative Medicine: “The study and man-agement
of patients with active, progressive, far advanced disease for whom
the prognosis is limited and the focus of care is the quality of life.” This is not
intended to exclude remissions and requires that the management of patients
be comprehensive, embracing the efforts of medical clinicians and of those
who provide psychosocial services, spiritual support, and hospice care. A
physician who provides palliative care, encompassing the full range of comfort
care, should assess his or her patient’s physical, psychological, and spiritual
conditions. Because of the overwhelming concern of patients about pain
relief, special attention should be given the effective assessment of pain. It is
particularly important that the physician frankly but sensitively discuss with
the patient and the family their concerns and choices at the end of life. As part
of this discussion, the physician should make clear that, in some cases, there
are inherent risks associated with effective pain relief in such situations.
Opioid Use
p The Board will assume opioid use in such patients is appropriate if the
responsible physician is familiar with and abides by acceptable medical guide-lines
regarding such use, is knowledgeable about effective and compassionate
pain relief, and maintains an appropriate medical record that details a pain
management plan. (See the Board’s position statement on the Management
of Chronic Non-Malignant Pain for an outline of what the Board expects of
physicians in the management of pain.) Because the Board is aware of the
inherent risks associated with effective pain relief in such situations, it will not
interpret their occurrence as subject to discipline by the Board.
Selected Guides
To assist physicians in meeting these responsibilities, the Board recommends
Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed (1996), Cancer
Pain Relief and Palliative Care (1990), Cancer Pain Relief and Palliative Care in
Children (1999), and Symptom Relief in Terminal Illness (1998), (World Health
Organization, Geneva); Management of Cancer Pain (1994), (Agency for
Health Care Policy and Research, Rockville, MD); Principles of Analgesic Use in
the Treatment of Acute Pain and Cancer Pain, 4th Edition (1999)(American
Pain Society, Glenview, IL); Hospice Care: A Physician’s Guide (1998)
(Hospice for the Carolinas, Raleigh); and the Oxford Textbook of Palliative
Medicine (1993) (Oxford Medical, Oxford).
(Adopted 10/1999)
*Steven A. Schroeder, MD, President, Robert Wood Johnson Foundation.
Joint Statement on Pain Management in End-of-Life Care (Adopted by
the North Carolina Medical, Nursing, and Pharmacy Boards)
p Through dialogue with members of the healthcare community and con-sumers,
a number of perceived regulatory barriers to adequate pain manage-ment
in end-of-life care have been expressed to the Boards of Medicine,
Nursing, and Pharmacy. The following statement attempts to address these
misperceptions by outlining practice expectations for physicians and other
healthcare professionals authorized to prescribe medications, as well as nurses
and pharmacists involved in this aspect of end-of-life care. The statement is
based on:
n the legal scope of practice for each of these licensed health professionals;
n professional collaboration and communication among health profession-als
providing palliative care; and
16 NCMB Forum
n a standard of care that assures on-going pain assessment, a therapeutic
plan for pain management interventions; and evidence of adequate symp-tom
management for the dying patient.
p It is the position of all three Boards that patients and their families should
be assured of competent, comprehensive palliative care at the end of their lives.
Physicians, nurses, and pharmacists should be knowledgeable regarding effec-tive
and compassionate pain relief, and patients and their families should be
assured such relief will be provided.
Because of the overwhelming concern of patients about pain relief, the
physician needs to give special attention to the effective assessment of pain. It
is particularly important that the physician frankly but sensitively discuss with
the patient and the family their concerns and choices at the end of life. As part
of this discussion, the physician should make clear that, in some end of life care
situations, there are inherent risks associated with effective pain relief. The
Medical Board will assume opioid use in such patients is appropriate if the
responsible physician is familiar with and abides by acceptable medical guide-lines
regarding such use, is knowledgeable about effective and compassionate
pain relief, and maintains an appropriate medical record that details a pain
management plan. Because the Board is aware of the inherent risks associat-ed
with effective pain relief in such situations, it will not interpret their occur-rence
as subject to discipline by the Board.
With regard to pharmacy practice, North Carolina has no quantity restric-tions
on dispensing controlled substances including those in Schedule II. This
is significant when utilizing the federal rule that allows the partial filling of
Schedule II prescriptions for up to 60 days. In these situations it would min-imize
expenses and unnecessary waste of drugs if the prescriber would note on
the prescription that the patient is terminally ill and specify the largest antici-pated
quantity that could be needed for the next two months. The pharma-cist
could then dispense smaller quantities of the prescription to meet the
patient’s needs up to the total quantity authorized. Government-approved
labeling for dosage level and frequency can be useful as guidance for patient
care. Health professionals may, on occasion, determine that higher levels are
justified in specific cases. However, these occasions would be exceptions to
general practice and would need to be properly documented to establish
informed consent of the patient and family.
Federal and state rules also allow the fax transmittal of an original prescrip-tion
for Schedule II drugs for hospice patients. If the prescriber notes the hos-pice
status of the patient on the faxed document, it serves as the original.
Pharmacy rules also allow the emergency refilling of prescriptions in Schedules
III, IV, and V. While this does not apply to Schedule II drugs, it can be use-ful
in situations where the patient is using drugs such as Vicodin for pain or
Xanax for anxiety.
The nurse is often the health professional most involved in on-going pain
assessment, implementing the prescribed pain management plan, evaluating
the patient’s response to such interventions and adjusting medication levels
based on patient status. In order to achieve adequate pain management, the
prescription must provide dosage ranges and frequency parameters within
which the nurse may adjust (titrate) medication in order to achieve adequate
pain control. Consistent with the licensee’s scope of practice, the RN or LPN
is accountable for implementing the pain management plan utilizing his/her
knowledge base and documented assessment of the patient’s needs. The nurse
has the authority to adjust medication levels within the dosage and frequency
ranges stipulated by the prescriber and according to the agency’s established
protocols. However, the nurse does not have the authority to change the med-ical
pain management plan. When adequate pain management is not achieved
under the currently prescribed treatment plan, the nurse is responsible for
reporting such findings to the prescriber and documenting this communica-tion.
Only the physician or other health professional with authority to pre-scribe
may change the medical pain management plan.
Communication and collaboration between members of the healthcare
team, and the patient and family are essential in achieving adequate pain man-agement
in end-of-life care. Within this interdisciplinary framework for end
of life care, effective pain management should include:
n thorough documentation of all aspects of the patient’s assessment and
care;
n a working diagnosis and therapeutic treatment plan including pharmaco-logic
and non-pharmacologic interventions;
n regular and documented evaluation of response to the interventions and,
as appropriate, revisions to the treatment plan;
n evidence of communication among care providers;
n education of the patient and family; and
n a clear understanding by the patient, the family and healthcare team of
the treatment goals.
It is important to remind health professionals that licensing boards hold
each licensee accountable for providing safe, effective care. Exercising this
standard of care requires the application of knowledge, skills, as well as ethical
principles focused on optimum patient care while taking all appropriate mea-sures
to relieve suffering. The healthcare team should give primary importance
to the expressed desires of the patient tempered by the judgement and legal
responsibilities of each licensed health professional as to what is in the patient’s
best interest.
(10/1999)
LASER SURGERY
p It is the position of the North Carolina Medical Board that the revision,
destruction, incision, or other structural alteration of human tissue using laser
technology is surgery.* Laser surgery should be performed only by a physi-cian
or by a licensed practitioner with appropriate medical training function-ing
under the supervision, preferably on-site, of a physician or by those cate-gories
of practitioners currently licensed by this state to perform surgical ser-vices.
Licensees should use only devices approved by the U.S. Food and Drug
Administration unless functioning under protocols approved by institutional
review boards. As with all new procedures, it is the licensee’s responsibility to
obtain adequate training and to make documentation of this training available
to the North Carolina Medical Board on request.
Lasers are employed in certain hair-removal procedures, as are various
devices that (1) manipulate and/or pulse light causing it to penetrate human
tissue and (2) are classified as “prescription” by the U.S. Food and Drug
Administration. Hair-removal procedures using such technologies should be
performed only by a physician or by a licensed practitioner with appropriate
medical training functioning under the supervision, preferably on-site, of a
physician who bears responsibility for those procedures.
*Definition of surgery as adopted by the NCMB, November 1998:
Surgery, which involves the revision, destruction, incision, or structural
alteration of human tissue performed using a variety of methods and instru-ments,
is a discipline that includes the operative and non-operative care of
individuals in need of such intervention, and demands pre-operative assess-ment,
judgment, technical skills, post-operative management, and follow
up.
(Adopted 7/1999)
(Amended 1/2000)
OPHTHALMOLOGISTS: CARE OF CATARACT PATIENTS
p The evaluation, diagnosis, and care of cataract surgical patients is primarily
the responsibility of the operating surgeon. The operating surgeon may not
delegate to optometrists, nurses, or anesthesiologists the responsibility of per-forming
an adequate preoperative examination. The surgeon must thorough-ly
examine each patient on whom he performs surgery prior to time for that
surgery. This thorough examination shall include a review of the patient’s his-tory
and an independent diagnosis by the operating surgeon of cataracts
requiring surgery. The operating surgeon shall have a detailed discussion with
each patient regarding the diagnosis and the nature of the cataract surgery,
advising the patient fully of the risks involved. All surgical decisions must be
made by the operating surgeon.
p Following surgery, the operating surgeon must perform the 24 hour post-operative
examination on every patient on whom he performs surgery, includ-ing
clear documentation of such examination in the patient record. In the case
of an emergency, the operating surgeon shall ensure that another ophthalmol-ogist
performs the 24 hour postoperative examination. Following the 24 hour
postoperative examination, the operating surgeon shall provide postoperative
care for each patient on whom he performs surgery until the healing process
is complete.
No. 4 1999 17
p It is not improper to involve non-physicians in postoperative care so long
as the operating surgeon maintains responsibility for the patient’s postopera-tive
care and examines the patient in the period following surgery to assess the
healing process and the long-term results.
p Even in the case of repetitive surgical procedures, a record should be kept
including detailed surgical notes describing each patient, his or her condition,
the procedures, methods, prostheses, results, prognosis, medication relative to
the surgery, and significant variations in each surgical procedure.
p The act of severing a suture following ophthalmologic surgery is a medical
act that can only be performed by the operating surgeon or by those health
care providers to whom this act may be legally delegated.
p It is improper to permit non-physicians to prescribe medication except as
provided by statute. In instances where the surgeon communicates and col-laborates
with an optometrist prescribing other than topical pharmaceutical
agents not used for the purpose of examining the eye, that communication and
collaboration must be contemporaneous with the issuance of any prescription
and specific for each patient.
(Adopted 9/1991)
HIV/HBV INFECTED HEALTH CARE WORKERS
The North Carolina Medical Board supports and adopts the North Carolina
Department of Environment, Health and Natural Resources Division of
Epidemiology’s rule for HIV and HBV Infected Health Care Workers
(T15A:19A.0207), and its rule for Infection Control in Health Care Settings
(T15A:19A.0206). It is the Board’s position that all licensees should be famil-iar
with the current requirements of those rules.
(Adopted 11/1992)
(Amended 5/1996)
PROFESSIONAL OBLIGATION TO REPORT INCOMPETENCE,
IMPAIRMENT, AND UNETHICAL CONDUCT
p It is the position of the North Carolina Medical Board that physicians have
a professional obligation to act when confronted with an impaired or incom-petent
colleague or one who has engaged in unethical conduct.
When appropriate, an offer of personal assistance to the colleague may be
the most compassionate and effective intervention. When this would not be
appropriate or sufficient to address the problem, physicians have a duty to
report the matter to the institution best positioned to deal with the problem.
For example, impaired physicians and physician assistants should be reported
to the North Carolina Physicians Health program. Incompetent physicians
should be reported to the clinical authority empowered to take appropriate
action. Physicians also may report to the North Carolina Medical Board, and
when there is no other institution reasonably likely to be able to deal with the
problem, this will be the only way of discharging the duty to report.
This duty is subordinate to the duty to maintain patient confidences. In
other words, when the colleague is a patient or when matters concerning a col-league
are brought to the physician’s attention by a patient, the physician must
give appropriate consideration to preserving the patient’s confidences in decid-ing
whether to report the colleague.
(Adopted 11/1998)
CONTINUING MEDICAL EDUCATION
p North Carolina physicians engaged in active clinical practice should obtain
regular, continuing medical education as a part of maintaining their compe-tence
to practice medicine with reasonable skill and safety.
p The North Carolina Medical Board strongly encourages its licensees who
are actively engaged in clinical practice to obtain and maintain documentation
of not less than one hundred fifty (150) hours of continuing medical educa-tion
every three years. The majority of these hours should be applicable to the
individual’s practice specialty.
(Adopted 5/1991)
(Amended 1/1992)
(Amended 5/1996)
FEE SPLITTING
p The North Carolina Medical Board endorses the AMA Code of Medical
Ethics Opinions 6.02, 6.03, and 6.04 condemning fee splitting. Fee splitting
may be receipt of money or something else of value in return for referrals or
remuneration from a drug or device manufacturer/distributor, a sales repre-sentative,
or another professional as an incentive for the use of that interested
party’s product.
p Except in instances permitted by law (NC Gen Stat 55B-14(c)), it is the
position of the Board that sharing profits between a non-physician or para-professional
and a physician partner on a percentage basis is also fee splitting
and is grounds for disciplinary action.
(Adopted 11/1993)
(Amended 5/1996)
UNETHICAL AGREEMENTS IN COMPLAINT SETTLEMENTS
It is the position of the North Carolina Medical Board that it is unethical for
a physician to settle any complaint if the settlement contains an agreement by
a patient not to complain or provide information to the Board.
(Adopted 11/1993)
(Amended 5/1996)
NORTH CAROLINA
MEDICAL BOARD SEEKS
MEDICAL
COORDINATOR
The North Carolina Medical Board is recruiting to
fill a vacancy in the staff position of Medical
Coordinator. The physician filling this position will
review, evaluate, and make recommendations to the
Board about reports concerning the conduct and/or
performance of physicians licensed to practice medi-cine
in North Carolina.
Any physician interested in being considered for the
full time position of Medical Coordinator must hold a
full and unrestricted North Carolina medical license
and should submit a curriculum vitae to:
Mr Andrew Watry,
Executive Director, North Carolina Medical Board
PO Box 20007
Raleigh, NC 27619
or
info@ncmedboard.org.
All inquiries regarding this position should be made
in writing and be directed to Mr Watry at either of the
addresses above. Application deadline is March 15,
2000.
18 NCMB Forum
ANNULMENTS
NONE
REVOCATIONS
POWELL, John Gary, MD
Location: Lynchburg, VA
DOB: 2/03/1939
License #: 0000-14750
Specialty: PD (as reported by physician)
Medical Ed: Duke University School of Medicine (1965)
Cause: On 3/09/1998, pursuant to a Consent Order with the Virginia
medical board, Dr Powell surrendered his license based on his
arrest for reproducing sexually explicit material that used or had
as a subject a person less than 18 years old, which is a Class 5
felony in Virginia.
Action: 8/04/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued: Dr Powell’s North Carolina license is revoked.
See Consent Orders:
MIJANOVICH, James Robert, MD
SUSPENSIONS
ANDERSON, Lorenzo James, Physician Assistant
Location: Greenville, SC
DOB: 10/30/1953
License #: 0001-02264
PA Education: Medical College of Georgia (1993)
Cause: Mr Anderson’s license to practice dentistry in Florida was
revoked by the dental board of that state on or about
10/14/1988; his dentistry license in Georgia was placed on pro-bation
for two years on or about 3/24/1989; in November 1990,
the Georgia dentistry board issued a Notice of Hearing on
charges concerning him; on 1/24/1991, he surrendered his den-tistry
license in Georgia; in November 1996, he applied for a PA
license in North Carolina; on his application form, he answered
“no” to questions asking if there had ever been disciplinary pro-ceedings
or investigations concerning him by governmental or
regulatory agencies, thus responding falsely so as to fraudulently
or deceptively obtain a license.
Action: 9/07/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued: Mr Anderson’s PA license is suspended. [See
also Consent Order of 10/27/1999 cited below.]
TANKSLEY, Marion Hollis, DO
Location: Hartfield, VA
DOB: 3/22/1937
License #: 0000-17192
Specialty: FP/AM (as reported by physician)
Medical Ed: Iowa College of Osteopathic Medicine (1968)
Cause: In May 1996, Dr Tanksley was convicted by General Court-
Martial at the Norfolk, VA, Naval Base of three violations of the
Uniform Code of Military Justice: while on active duty he failed
to obtain permission to work as a part-time civilian physician
from May through June 1994; with intent to deceive, he falsely
responded to a Personnel Security Questionnaire, to a Defense
Investigative Service Special Agent, to questions on a Personal
and Professional Information Sheet, to a DIS Special Agent as
part of an official statement, and to the president of the Navy
Physical Evaluation Board; in August 1993, he took indecent
liberties with a female under 16 years of age; in November 1993,
he wrongfully attempted to hinder a Navy investigation and to
intimidate witnesses; and in December 1993, he made false
statements under oath. These convictions were affirmed by the
U.S. Navy-Marine Corps Court of Criminal appeals in 1999. In
February 1997, the Virginia Board of Medicine, in consideration
of these convictions, suspended Dr Tanksley’s medical license,
the suspension being stayed on terms and conditions. In April,
1999, the Virginia Board terminated the terms and conditions
imposed on Dr Tanksley’s license and reinstated his license to full
and unrestricted status. In May 1998, the Composite State
Board of Medical Examiners of Georgia, acting in consideration
of the convictions, placed his medical license on indefinite pro-bation
with terms and conditions.
Action: 8/24/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued following a hearing before the North Carolina
Medical Board on July 22, 1999. Dr Tanksley’s medical license
is suspended indefinitely. All but 90 days of the suspension will
be stayed if, within 90 days, Dr Tanksley signs a Consent Order
in the form attached to this Order. The Consent Order would
reprimand Dr Tanksley and place terms and conditions on his
license.
See Consent Orders:
JUBERG, Breton Chester, MD
WASHINGTON, Clarence Joseph, III, MD
SUMMARY SUSPENSIONS
DECLERCK, Paul A., MD
Location: Kinston, NC (Lenoir Co)
DOB: 10/07/1947
License #: 0000-24240
Specialty: FP (as reported by physician)
Medical Ed: University of Brussels, Belgium (1975)
Cause: As alleged in the Notice of Charges and Allegations, it appears
to the Board that Dr DeClerck may be unable to practice medi-cine
with reasonable skill and safety by reason of illness, drunk-enness,
excessive use of alcohol, drugs, chemicals, or any other
type of materials or by reason of any physical or mental abnor-mality
within the meaning of the applicable law.
Action: 8/30/1999. Order of Summary Suspension of License issued,
effective September 2, 1999. [See also Surrender of 9/01/1999
cited below.]
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
August, September, October 1999
DEFINITIONS
PETERSON, William, MD
Location: Rutherfordton, NC (Rutherford Co)
DOB: 1/15/1949
License #: 0096-01432
Specialty: N/CN (as reported by physician)
Medical Ed: Hahnemann School of Medicine (1975)
Cause: Dr Peterson may be unable to practice medicine with reasonable
skill and safety by reason of illness, drunkenness, excessive use of
alcohol, drugs, chemicals, or any other type of material or by rea-son
of a physical or mental abnormality within the meaning of
the law.
Action: 8/02/1999. Order of Summary Suspension of License issued,
effective August 12, 1999. [Notice of Charges dated 8/02/1999
alleging inability to practice with reasonable skill and safety and
unresponsiveness to calls from the hospital while on call.]
WORIAX, Eric, Physician